Medicolegal Issues

In This Edition

Literature at a Glance

A guide to this month’s studies

• Risk of VTE with travel
• Hyponatremia and mortality
• Clopidogrel and aspirin for atrial fibrillation
• Cost-effective evaluation of syncope
• Early vs. delayed intervention in STEMI patients receiving fibrinolytics
• Predictors of prolonged SSU length of stay
• Rates of survival for in-hospital CPR
• Hospitalists and hospital quality measures

 

Travel Increases Risk for Venous Thromboembolism in a Dose-Response Relationship

Clinical question: What is the association between travel and the risk of venous thromboembolism (VTE)?

Background: Previous studies evaluating the relationship between long-distance travel and VTE have been heterogeneous and inconclusive. Though a relationship is often discussed, only about half of prior investigations have identified an elevated VTE risk in those who travel, and the impact of duration on VTE risk is unclear.

Study design: Meta-analysis.

Setting: Western countries.

Synopsis: Studies were included if they investigated the association between travel and VTE for persons using any mode of transportation and if nontraveling persons were included for comparison. Fourteen studies met the criteria, and included 4,055 patients with VTE. Compared with nontravelers, the overall pooled relative risk for VTE in travelers was 2.0 (95% CI, 1.5-2.7).

Significant heterogeneity was present among these 14 studies, specifically with regard to the method used for selecting control participants. Six case-control studies used control patients who had been referred for VTE evaluation. When these studies were excluded, the pooled relative risk for VTE in travelers was 2.8 (95% CI, 2.2-3.7).

A dose-response relationship was identified. There was an 18% higher risk for VTE for each two-hour increase in duration of travel among all modes of transportation (P=0.010). When studies evaluating only air travel were analyzed, a 26% higher risk was found for every two-hour increase in air travel (P=0.005).

Bottom line: Travel is associated with a three-fold increase in the risk for VTE, and for each two-hour increase in travel duration, the risk increases approximately 18%.

Citation: Chandra D, Parisini E, Mozaffarian D. Meta-analysis: travel and risk for venous thromboembolism. Ann Intern Med. 2009;151(3):180-190.

 

Hyponatremia in Hospitalized Patients is Associated with Increased Mortality

Clinical question: Is hyponatremia in hospitalized patients associated with increased mortality?

Background: Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Patients admitted with hyponatremia have increased in-hospital mortality. Long-term mortality in hospitalized patients with hyponatremia is not known. Further, the effects of the degree of hyponatremia on mortality are not known.

Study design: Prospective cohort.

Setting: Two teaching hospitals in Boston.

Synopsis: The study identified 14,290 patients with hyponatremia (serum sodium <135 mEq/L) at admission (14.5%) and an additional 5,093 patients (19,383 total patients, or 19.7% of the 98,411 study patients) with hyponatremia at some point during their hospital stay. After multivariable adjustments and correction for hyperglycemia, patients with hyponatremia had increased mortality in the hospital (OR 1.47, 95% CI, 1.33-1.62), at one year (HR 1.38, 95% CI, 1.32-1.46), and at five years (HR 1.25, 95% CI, 1.21-1.30) compared with normonatremic patients. These mortality differences were seen in patients with mild, moderate, and moderately severe hyponatremia (serum sodium concentrations 130-134, 125-129, and 120-124 mEq/L, respectively), but not in patients with severe hyponatremia (serum sodium <120 mEq/L).

 

This study is limited by its post-hoc identification and classification of patients using ICD-9-CM codes, which could have resulted in some misclassification. Also, this study includes only two teaching hospitals in an urban setting; the prevalence of hyponatremia might differ in other settings. Causality cannot be determined based on these results.

Bottom line: Hospitalized patients with hyponatremia have increased in-hospital and long-term mortality.

Citation: Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med. 2009;122(9):857-865.

 

Clopidogrel Plus Aspirin in Patients with Atrial Fibrillation Reduces Risk of Major Vascular Events

Clinical question: Does the addition of clopidogrel to aspirin therapy reduce the risk of major vascular events in patients with atrial fibrillation for whom vitamin K antagonists (VKAs) are unsuitable?

Background: Although VKAs reduce the risk of stroke in atrial fibrillation, many patients are unable to use VKAs and are treated with aspirin instead. The potential benefits of adding clopidogrel to aspirin therapy in this population are unknown.

Study design: Randomized controlled trial.

Setting: Five hundred eighty medical centers in 33 countries.

Synopsis: More than 7,500 patients with atrial fibrillation who were also at high risk for stroke were randomly assigned to receive either clopidogrel or placebo once daily. All patients also received aspirin at a dose of 75 mg to 100 mg daily. A major vascular event occurred in 6.8% of patients per year who received clopidogrel and in 7.6% of patients per year who received placebo (RR 0.89, 95% CI, 0.89-0.98, P=0.01). This reduction primarily was due to a reduction in stroke, which occurred in 2.4% of patients per year who received clopidogrel, compared with 3.3% of patients per year who received placebo (RR 0.72, 95% CI, 0.62-0.83, P<0.001).

Major bleeding occurred in 2% of patients per year who received clopidogrel and in 1.3% of patients per year who received placebo (RR 1.57, 95% CI, 1.29-1.92, P<0.001).

Bottom line: Adding clopidogrel to aspirin in patients with atrial fibrillation who are not eligible for VKAs decreases the risk of major vascular events, including stroke, but increases risk of major hemorrhage compared with aspirin alone.

Citation: ACTIVE Investigators, Connolly SJ, Pogue J, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360(20):2066-2078.

 

 

Prioritize Syncope Testing by Diagnostic Yield and Cost Effectiveness

Clinical question: What are the utilization, yield, and cost effectiveness of tests used for evaluation of syncope in older patients?

Background: Clinicians utilize multiple diagnostic tests to help delineate the cause of syncope, but the yield and cost effectiveness of many of these tests are unclear. Further, it is unknown if considering patient characteristics, as in the San Francisco syncope rule (SFSR), can improve the yield of diagnostic tests.

Study design: Retrospective cohort.

Setting: Single acute-care hospital.

Synopsis: Review of 2,106 admissions in patients 65 and older with syncope revealed that the most common tests were electrocardiogram (99%), telemetry (95%), cardiac enzymes (95%), and head computed tomography (CT) scan (63%). The majority of tests did not affect diagnosis or management.

Postural blood pressure (BP) reading was infrequently recorded (38%) but had the highest yield. BP influenced diagnosis at least 18% of the time and management at least 25% of the time. Tests with the lowest likelihood of affecting diagnosis and management were head CT, carotid ultrasound, electroencephalography (EEG), and cardiac enzymes.

EEG had the highest cost per test affecting the diagnosis or management ($32,973), followed by head CT. The cost per test affecting diagnosis or management for postural BP was $17. Cardiac testing, including telemetry, echocardiogram, and cardiac enzymes, had significantly better yield in patients who met SFSR criteria.

Bottom line: In patients with syncope, the history and exam should guide evaluation, and tests with high yield and low cost per test, such as postural BP, should be prioritized.

Citation: Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169(14): 1299-1305.

 

Early PCI is Superior to Delayed Intervention in Patients with STEMI Receiving Fibrinolytic Therapy

Clinical question: Does early percutaneous coronary intervention (PCI) improve clinical outcomes compared with standard management in patients with ST elevation myocardial infarction (STEMI) who receive fibrinolysis?

Background: Prior research has demonstrated the benefit of timely PCI in the management of acute coronary syndrome, specifically with ST elevation. However, many hospitals do not have this capability and utilize fibrinolysis as a standard alternative. The optimal timing of subsequent invasive intervention following fibrinolysis has not been established.

Study design: Multicenter randomized trial.

Setting: Fifty-two sites in three provinces in Canada.

Synopsis: This study randomized 1,059 patients presenting with STEMI and receiving fibrinolysis to early intervention (immediate transfer to another hospital with PCI less than six hours after fibrinolysis) versus standard intervention (rescue PCI if needed, or delayed angiography at more than 24 hours). The primary outcome was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days.

The primary outcome occurred in 11% of patients in the early intervention group, compared with 17.2% of patients randomized to standard intervention (RR 0.64, 95% CI, 0.47-0.87, P=0.004). Urgent catheterization was performed within 12 hours of fibrinolysis in 34.9% of patients randomized to the standard treatment group.

This study was not powered to detect differences in mortality and other individual components of the primary endpoint.

Bottom line: STEMI patients who received fibrinolysis had a lower risk of adverse outcomes when receiving transfer and PCI within six hours, compared with standard delayed intervention.

Citation: Cantor WJ, Fitchett D, Borgundvaag B, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009;360(26):2705-2718.

 

Specialty Consultation and Limited Access Tests Predict Unsuccessful SSU Admissions

 

Clinical question: In patients admitted to short-stay units (SSUs), what characteristics are associated with unsuccessful SSU admission?

Background: Short-stay units have become prevalent in U.S. hospitals, but it is unclear which patient populations are best served by SSUs.

Study design: Prospective cohort.

Setting: Fourteen-bed SSU in a 500-bed public teaching hospital in Chicago.

Synopsis: More than 700 patients admitted to the Cook County Hospital SSU over a four-month period were interviewed and examined, and their ED and inpatient records were reviewed. An SSU admission was defined as “successful” if the length of stay (LOS) was less than 72 hours and the patient was discharged directly from the SSU.

Overall, 79% of patients had a successful SSU admission. In multivariate analysis, the strongest predictors of an unsuccessful SSU stay were subspecialty consultation (OR 8.1, P<0.001), a provisional diagnosis of heart failure (OR 1.9, P=0.02), and limited availability of a diagnostic test (OR 2.5, P<0.001).

The study was limited primarily to patients with cardiovascular diagnoses.

Bottom line: Patients admitted to SSUs who receive specialty consultation, carry a diagnosis of heart failure, or require diagnostic testing that is not readily available might have a longer LOS or eventual inpatient admission.

Citation: Lucas BP, Kumapley R, Mba B, et al. A hospitalist-run short-stay unit: features that predict length-of-stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276-284.

 

Lack of Significant Gains in Survival Rates Following In-Hospital CPR

Clinical question: Is survival after in-hospital CPR improving over time, and what are the factors associated with survival?

Background: Advances in out-of-hospital CPR have improved outcomes. However, it is unknown whether the survival rate after in-hospital CPR is improving over time, and it is unclear which patient and/or hospital characteristics predict post-CPR survival.

Study design: Retrospective cohort.

Setting: Inpatient Medicare beneficiaries from 1992 to 2005.

Synopsis: The study examined more than 150 million Medicare admissions, 433,985 of which underwent in-hospital CPR. Survival to discharge occurred in 18.3% of CPR events and did not change significantly from 1992 to 2005. The cumulative incidence of in-hospital CPR events was 2.73 per 1,000 admissions; it did not change substantially over time.

The survival rate was lower among black patients (OR 0.76, 95% CI, 0.74-0.79), which is partially explained due to the fact they tended to receive CPR at hospitals with lower post-CPR survival. Gender (specifically male), older age, race (specifically other nonwhite patients), higher burden of chronic illness, and admission from a skilled nursing facility were significantly associated with decreased survival to hospital discharge following CPR.

Limitations of this study included the identification of CPR by ICD-9 codes, which have not been validated for this purpose and could vary among hospitals. Other factors that might explain variations in survival were not available, including severity of acute illness and the presence (or absence) of a shockable rhythm at initial presentation.

Bottom line: Rates of survival to hospital discharge among Medicare beneficiaries receiving in-hospital CPR have remained constant over time, with poorer survival rates among blacks and other nonwhite patients.

Citation: Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.

 

Hospitalists Are Associated with Improved Performance on Quality Metrics

Clinical question: Is the presence of hospitalist physicians associated with improved performance on standard quality measures for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia?

Background: Previous investigations have demonstrated significant improvements in cost and LOS for patients under the care of hospitalists compared with other inpatient providers. The association between hospitalist prevalence and quality of care, as measured by standard quality process measures, is unknown.

 

Study design: Cross-sectional.

Setting: More than 3,600 hospitals participating in the Health Quality Alliance (HQA) program.

Synopsis: Investigators looked at a large sample of HQA hospitals in the American Hospital Association survey, and identified facilities with hospitalist services and those without. The primary endpoint was the adherence to composites of standard quality process measures across three disease categories (AMI, CHF, and pneumonia) and two domains of care (disease treatment/diagnosis and counseling/prevention).

Multivariable analyses revealed a statistically significant association between the presence of hospitalists and adherence to composite quality measures for AMI and pneumonia. This association was demonstrated for both treatment and counseling domains.

The study is cross-sectional, so conclusions cannot be drawn about causality. Also, there are likely unmeasured differences between hospitals that utilize hospitalists compared with those that do not, which could further confound the relationship between the presence of hospitalists and adherence to quality measures.

Finally, this study only evaluated hospital-level performance, and it cannot offer insight on the quality of individual patient care by hospitalist providers.

Bottom line: The presence of hospitalists is associated with improvement in adherence to quality measures for both AMI and pneumonia, and across clinical domains of treatment and counseling.

Citation: López L, Hicks LS, Cohen AP, McKean S, Weissman JS. Hospitalists and the quality of care in hospitals. Arch Intern Med. 2009;169(15):1389-1394. TH

 

In This Edition

Literature at a Glance

A guide to this month’s studies

• Risk of VTE with travel
• Hyponatremia and mortality
• Clopidogrel and aspirin for atrial fibrillation
• Cost-effective evaluation of syncope
• Early vs. delayed intervention in STEMI patients receiving fibrinolytics
• Predictors of prolonged SSU length of stay
• Rates of survival for in-hospital CPR
• Hospitalists and hospital quality measures

 

Travel Increases Risk for Venous Thromboembolism in a Dose-Response Relationship

Clinical question: What is the association between travel and the risk of venous thromboembolism (VTE)?

Background: Previous studies evaluating the relationship between long-distance travel and VTE have been heterogeneous and inconclusive. Though a relationship is often discussed, only about half of prior investigations have identified an elevated VTE risk in those who travel, and the impact of duration on VTE risk is unclear.

Study design: Meta-analysis.

Setting: Western countries.

Synopsis: Studies were included if they investigated the association between travel and VTE for persons using any mode of transportation and if nontraveling persons were included for comparison. Fourteen studies met the criteria, and included 4,055 patients with VTE. Compared with nontravelers, the overall pooled relative risk for VTE in travelers was 2.0 (95% CI, 1.5-2.7).

Significant heterogeneity was present among these 14 studies, specifically with regard to the method used for selecting control participants. Six case-control studies used control patients who had been referred for VTE evaluation. When these studies were excluded, the pooled relative risk for VTE in travelers was 2.8 (95% CI, 2.2-3.7).

A dose-response relationship was identified. There was an 18% higher risk for VTE for each two-hour increase in duration of travel among all modes of transportation (P=0.010). When studies evaluating only air travel were analyzed, a 26% higher risk was found for every two-hour increase in air travel (P=0.005).

Bottom line: Travel is associated with a three-fold increase in the risk for VTE, and for each two-hour increase in travel duration, the risk increases approximately 18%.

Citation: Chandra D, Parisini E, Mozaffarian D. Meta-analysis: travel and risk for venous thromboembolism. Ann Intern Med. 2009;151(3):180-190.

 

Hyponatremia in Hospitalized Patients is Associated with Increased Mortality

Clinical question: Is hyponatremia in hospitalized patients associated with increased mortality?

Background: Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Patients admitted with hyponatremia have increased in-hospital mortality. Long-term mortality in hospitalized patients with hyponatremia is not known. Further, the effects of the degree of hyponatremia on mortality are not known.

Study design: Prospective cohort.

Setting: Two teaching hospitals in Boston.

Synopsis: The study identified 14,290 patients with hyponatremia (serum sodium <135 mEq/L) at admission (14.5%) and an additional 5,093 patients (19,383 total patients, or 19.7% of the 98,411 study patients) with hyponatremia at some point during their hospital stay. After multivariable adjustments and correction for hyperglycemia, patients with hyponatremia had increased mortality in the hospital (OR 1.47, 95% CI, 1.33-1.62), at one year (HR 1.38, 95% CI, 1.32-1.46), and at five years (HR 1.25, 95% CI, 1.21-1.30) compared with normonatremic patients. These mortality differences were seen in patients with mild, moderate, and moderately severe hyponatremia (serum sodium concentrations 130-134, 125-129, and 120-124 mEq/L, respectively), but not in patients with severe hyponatremia (serum sodium <120 mEq/L).

 

This study is limited by its post-hoc identification and classification of patients using ICD-9-CM codes, which could have resulted in some misclassification. Also, this study includes only two teaching hospitals in an urban setting; the prevalence of hyponatremia might differ in other settings. Causality cannot be determined based on these results.

Bottom line: Hospitalized patients with hyponatremia have increased in-hospital and long-term mortality.

Citation: Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med. 2009;122(9):857-865.

 

Clopidogrel Plus Aspirin in Patients with Atrial Fibrillation Reduces Risk of Major Vascular Events

Clinical question: Does the addition of clopidogrel to aspirin therapy reduce the risk of major vascular events in patients with atrial fibrillation for whom vitamin K antagonists (VKAs) are unsuitable?

Background: Although VKAs reduce the risk of stroke in atrial fibrillation, many patients are unable to use VKAs and are treated with aspirin instead. The potential benefits of adding clopidogrel to aspirin therapy in this population are unknown.

Study design: Randomized controlled trial.

Setting: Five hundred eighty medical centers in 33 countries.

Synopsis: More than 7,500 patients with atrial fibrillation who were also at high risk for stroke were randomly assigned to receive either clopidogrel or placebo once daily. All patients also received aspirin at a dose of 75 mg to 100 mg daily. A major vascular event occurred in 6.8% of patients per year who received clopidogrel and in 7.6% of patients per year who received placebo (RR 0.89, 95% CI, 0.89-0.98, P=0.01). This reduction primarily was due to a reduction in stroke, which occurred in 2.4% of patients per year who received clopidogrel, compared with 3.3% of patients per year who received placebo (RR 0.72, 95% CI, 0.62-0.83, P<0.001).

Major bleeding occurred in 2% of patients per year who received clopidogrel and in 1.3% of patients per year who received placebo (RR 1.57, 95% CI, 1.29-1.92, P<0.001).

Bottom line: Adding clopidogrel to aspirin in patients with atrial fibrillation who are not eligible for VKAs decreases the risk of major vascular events, including stroke, but increases risk of major hemorrhage compared with aspirin alone.

Citation: ACTIVE Investigators, Connolly SJ, Pogue J, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360(20):2066-2078.

 

 

Prioritize Syncope Testing by Diagnostic Yield and Cost Effectiveness

Clinical question: What are the utilization, yield, and cost effectiveness of tests used for evaluation of syncope in older patients?

Background: Clinicians utilize multiple diagnostic tests to help delineate the cause of syncope, but the yield and cost effectiveness of many of these tests are unclear. Further, it is unknown if considering patient characteristics, as in the San Francisco syncope rule (SFSR), can improve the yield of diagnostic tests.

Study design: Retrospective cohort.

Setting: Single acute-care hospital.

Synopsis: Review of 2,106 admissions in patients 65 and older with syncope revealed that the most common tests were electrocardiogram (99%), telemetry (95%), cardiac enzymes (95%), and head computed tomography (CT) scan (63%). The majority of tests did not affect diagnosis or management.

Postural blood pressure (BP) reading was infrequently recorded (38%) but had the highest yield. BP influenced diagnosis at least 18% of the time and management at least 25% of the time. Tests with the lowest likelihood of affecting diagnosis and management were head CT, carotid ultrasound, electroencephalography (EEG), and cardiac enzymes.

EEG had the highest cost per test affecting the diagnosis or management ($32,973), followed by head CT. The cost per test affecting diagnosis or management for postural BP was $17. Cardiac testing, including telemetry, echocardiogram, and cardiac enzymes, had significantly better yield in patients who met SFSR criteria.

Bottom line: In patients with syncope, the history and exam should guide evaluation, and tests with high yield and low cost per test, such as postural BP, should be prioritized.

Citation: Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169(14): 1299-1305.

 

Early PCI is Superior to Delayed Intervention in Patients with STEMI Receiving Fibrinolytic Therapy

Clinical question: Does early percutaneous coronary intervention (PCI) improve clinical outcomes compared with standard management in patients with ST elevation myocardial infarction (STEMI) who receive fibrinolysis?

Background: Prior research has demonstrated the benefit of timely PCI in the management of acute coronary syndrome, specifically with ST elevation. However, many hospitals do not have this capability and utilize fibrinolysis as a standard alternative. The optimal timing of subsequent invasive intervention following fibrinolysis has not been established.

Study design: Multicenter randomized trial.

Setting: Fifty-two sites in three provinces in Canada.

Synopsis: This study randomized 1,059 patients presenting with STEMI and receiving fibrinolysis to early intervention (immediate transfer to another hospital with PCI less than six hours after fibrinolysis) versus standard intervention (rescue PCI if needed, or delayed angiography at more than 24 hours). The primary outcome was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days.

The primary outcome occurred in 11% of patients in the early intervention group, compared with 17.2% of patients randomized to standard intervention (RR 0.64, 95% CI, 0.47-0.87, P=0.004). Urgent catheterization was performed within 12 hours of fibrinolysis in 34.9% of patients randomized to the standard treatment group.

This study was not powered to detect differences in mortality and other individual components of the primary endpoint.

Bottom line: STEMI patients who received fibrinolysis had a lower risk of adverse outcomes when receiving transfer and PCI within six hours, compared with standard delayed intervention.

Citation: Cantor WJ, Fitchett D, Borgundvaag B, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009;360(26):2705-2718.

 

Specialty Consultation and Limited Access Tests Predict Unsuccessful SSU Admissions

 

Clinical question: In patients admitted to short-stay units (SSUs), what characteristics are associated with unsuccessful SSU admission?

Background: Short-stay units have become prevalent in U.S. hospitals, but it is unclear which patient populations are best served by SSUs.

Study design: Prospective cohort.

Setting: Fourteen-bed SSU in a 500-bed public teaching hospital in Chicago.

Synopsis: More than 700 patients admitted to the Cook County Hospital SSU over a four-month period were interviewed and examined, and their ED and inpatient records were reviewed. An SSU admission was defined as “successful” if the length of stay (LOS) was less than 72 hours and the patient was discharged directly from the SSU.

Overall, 79% of patients had a successful SSU admission. In multivariate analysis, the strongest predictors of an unsuccessful SSU stay were subspecialty consultation (OR 8.1, P<0.001), a provisional diagnosis of heart failure (OR 1.9, P=0.02), and limited availability of a diagnostic test (OR 2.5, P<0.001).

The study was limited primarily to patients with cardiovascular diagnoses.

Bottom line: Patients admitted to SSUs who receive specialty consultation, carry a diagnosis of heart failure, or require diagnostic testing that is not readily available might have a longer LOS or eventual inpatient admission.

Citation: Lucas BP, Kumapley R, Mba B, et al. A hospitalist-run short-stay unit: features that predict length-of-stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276-284.

 

Lack of Significant Gains in Survival Rates Following In-Hospital CPR

Clinical question: Is survival after in-hospital CPR improving over time, and what are the factors associated with survival?

Background: Advances in out-of-hospital CPR have improved outcomes. However, it is unknown whether the survival rate after in-hospital CPR is improving over time, and it is unclear which patient and/or hospital characteristics predict post-CPR survival.

Study design: Retrospective cohort.

Setting: Inpatient Medicare beneficiaries from 1992 to 2005.

Synopsis: The study examined more than 150 million Medicare admissions, 433,985 of which underwent in-hospital CPR. Survival to discharge occurred in 18.3% of CPR events and did not change significantly from 1992 to 2005. The cumulative incidence of in-hospital CPR events was 2.73 per 1,000 admissions; it did not change substantially over time.

The survival rate was lower among black patients (OR 0.76, 95% CI, 0.74-0.79), which is partially explained due to the fact they tended to receive CPR at hospitals with lower post-CPR survival. Gender (specifically male), older age, race (specifically other nonwhite patients), higher burden of chronic illness, and admission from a skilled nursing facility were significantly associated with decreased survival to hospital discharge following CPR.

Limitations of this study included the identification of CPR by ICD-9 codes, which have not been validated for this purpose and could vary among hospitals. Other factors that might explain variations in survival were not available, including severity of acute illness and the presence (or absence) of a shockable rhythm at initial presentation.

Bottom line: Rates of survival to hospital discharge among Medicare beneficiaries receiving in-hospital CPR have remained constant over time, with poorer survival rates among blacks and other nonwhite patients.

Citation: Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.

 

Hospitalists Are Associated with Improved Performance on Quality Metrics

Clinical question: Is the presence of hospitalist physicians associated with improved performance on standard quality measures for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia?

Background: Previous investigations have demonstrated significant improvements in cost and LOS for patients under the care of hospitalists compared with other inpatient providers. The association between hospitalist prevalence and quality of care, as measured by standard quality process measures, is unknown.

 

Study design: Cross-sectional.

Setting: More than 3,600 hospitals participating in the Health Quality Alliance (HQA) program.

Synopsis: Investigators looked at a large sample of HQA hospitals in the American Hospital Association survey, and identified facilities with hospitalist services and those without. The primary endpoint was the adherence to composites of standard quality process measures across three disease categories (AMI, CHF, and pneumonia) and two domains of care (disease treatment/diagnosis and counseling/prevention).

Multivariable analyses revealed a statistically significant association between the presence of hospitalists and adherence to composite quality measures for AMI and pneumonia. This association was demonstrated for both treatment and counseling domains.

The study is cross-sectional, so conclusions cannot be drawn about causality. Also, there are likely unmeasured differences between hospitals that utilize hospitalists compared with those that do not, which could further confound the relationship between the presence of hospitalists and adherence to quality measures.

Finally, this study only evaluated hospital-level performance, and it cannot offer insight on the quality of individual patient care by hospitalist providers.

Bottom line: The presence of hospitalists is associated with improvement in adherence to quality measures for both AMI and pneumonia, and across clinical domains of treatment and counseling.

Citation: López L, Hicks LS, Cohen AP, McKean S, Weissman JS. Hospitalists and the quality of care in hospitals. Arch Intern Med. 2009;169(15):1389-1394. TH

 

In This Edition

Literature at a Glance

A guide to this month’s studies

• Risk of VTE with travel
• Hyponatremia and mortality
• Clopidogrel and aspirin for atrial fibrillation
• Cost-effective evaluation of syncope
• Early vs. delayed intervention in STEMI patients receiving fibrinolytics
• Predictors of prolonged SSU length of stay
• Rates of survival for in-hospital CPR
• Hospitalists and hospital quality measures

 

Travel Increases Risk for Venous Thromboembolism in a Dose-Response Relationship

Clinical question: What is the association between travel and the risk of venous thromboembolism (VTE)?

Background: Previous studies evaluating the relationship between long-distance travel and VTE have been heterogeneous and inconclusive. Though a relationship is often discussed, only about half of prior investigations have identified an elevated VTE risk in those who travel, and the impact of duration on VTE risk is unclear.

Study design: Meta-analysis.

Setting: Western countries.

Synopsis: Studies were included if they investigated the association between travel and VTE for persons using any mode of transportation and if nontraveling persons were included for comparison. Fourteen studies met the criteria, and included 4,055 patients with VTE. Compared with nontravelers, the overall pooled relative risk for VTE in travelers was 2.0 (95% CI, 1.5-2.7).

Significant heterogeneity was present among these 14 studies, specifically with regard to the method used for selecting control participants. Six case-control studies used control patients who had been referred for VTE evaluation. When these studies were excluded, the pooled relative risk for VTE in travelers was 2.8 (95% CI, 2.2-3.7).

A dose-response relationship was identified. There was an 18% higher risk for VTE for each two-hour increase in duration of travel among all modes of transportation (P=0.010). When studies evaluating only air travel were analyzed, a 26% higher risk was found for every two-hour increase in air travel (P=0.005).

Bottom line: Travel is associated with a three-fold increase in the risk for VTE, and for each two-hour increase in travel duration, the risk increases approximately 18%.

Citation: Chandra D, Parisini E, Mozaffarian D. Meta-analysis: travel and risk for venous thromboembolism. Ann Intern Med. 2009;151(3):180-190.

 

Hyponatremia in Hospitalized Patients is Associated with Increased Mortality

Clinical question: Is hyponatremia in hospitalized patients associated with increased mortality?

Background: Hyponatremia is the most common electrolyte abnormality in hospitalized patients. Patients admitted with hyponatremia have increased in-hospital mortality. Long-term mortality in hospitalized patients with hyponatremia is not known. Further, the effects of the degree of hyponatremia on mortality are not known.

Study design: Prospective cohort.

Setting: Two teaching hospitals in Boston.

Synopsis: The study identified 14,290 patients with hyponatremia (serum sodium <135 mEq/L) at admission (14.5%) and an additional 5,093 patients (19,383 total patients, or 19.7% of the 98,411 study patients) with hyponatremia at some point during their hospital stay. After multivariable adjustments and correction for hyperglycemia, patients with hyponatremia had increased mortality in the hospital (OR 1.47, 95% CI, 1.33-1.62), at one year (HR 1.38, 95% CI, 1.32-1.46), and at five years (HR 1.25, 95% CI, 1.21-1.30) compared with normonatremic patients. These mortality differences were seen in patients with mild, moderate, and moderately severe hyponatremia (serum sodium concentrations 130-134, 125-129, and 120-124 mEq/L, respectively), but not in patients with severe hyponatremia (serum sodium <120 mEq/L).

 

This study is limited by its post-hoc identification and classification of patients using ICD-9-CM codes, which could have resulted in some misclassification. Also, this study includes only two teaching hospitals in an urban setting; the prevalence of hyponatremia might differ in other settings. Causality cannot be determined based on these results.

Bottom line: Hospitalized patients with hyponatremia have increased in-hospital and long-term mortality.

Citation: Waikar SS, Mount DB, Curhan GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med. 2009;122(9):857-865.

 

Clopidogrel Plus Aspirin in Patients with Atrial Fibrillation Reduces Risk of Major Vascular Events

Clinical question: Does the addition of clopidogrel to aspirin therapy reduce the risk of major vascular events in patients with atrial fibrillation for whom vitamin K antagonists (VKAs) are unsuitable?

Background: Although VKAs reduce the risk of stroke in atrial fibrillation, many patients are unable to use VKAs and are treated with aspirin instead. The potential benefits of adding clopidogrel to aspirin therapy in this population are unknown.

Study design: Randomized controlled trial.

Setting: Five hundred eighty medical centers in 33 countries.

Synopsis: More than 7,500 patients with atrial fibrillation who were also at high risk for stroke were randomly assigned to receive either clopidogrel or placebo once daily. All patients also received aspirin at a dose of 75 mg to 100 mg daily. A major vascular event occurred in 6.8% of patients per year who received clopidogrel and in 7.6% of patients per year who received placebo (RR 0.89, 95% CI, 0.89-0.98, P=0.01). This reduction primarily was due to a reduction in stroke, which occurred in 2.4% of patients per year who received clopidogrel, compared with 3.3% of patients per year who received placebo (RR 0.72, 95% CI, 0.62-0.83, P<0.001).

Major bleeding occurred in 2% of patients per year who received clopidogrel and in 1.3% of patients per year who received placebo (RR 1.57, 95% CI, 1.29-1.92, P<0.001).

Bottom line: Adding clopidogrel to aspirin in patients with atrial fibrillation who are not eligible for VKAs decreases the risk of major vascular events, including stroke, but increases risk of major hemorrhage compared with aspirin alone.

Citation: ACTIVE Investigators, Connolly SJ, Pogue J, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360(20):2066-2078.

 

 

Prioritize Syncope Testing by Diagnostic Yield and Cost Effectiveness

Clinical question: What are the utilization, yield, and cost effectiveness of tests used for evaluation of syncope in older patients?

Background: Clinicians utilize multiple diagnostic tests to help delineate the cause of syncope, but the yield and cost effectiveness of many of these tests are unclear. Further, it is unknown if considering patient characteristics, as in the San Francisco syncope rule (SFSR), can improve the yield of diagnostic tests.

Study design: Retrospective cohort.

Setting: Single acute-care hospital.

Synopsis: Review of 2,106 admissions in patients 65 and older with syncope revealed that the most common tests were electrocardiogram (99%), telemetry (95%), cardiac enzymes (95%), and head computed tomography (CT) scan (63%). The majority of tests did not affect diagnosis or management.

Postural blood pressure (BP) reading was infrequently recorded (38%) but had the highest yield. BP influenced diagnosis at least 18% of the time and management at least 25% of the time. Tests with the lowest likelihood of affecting diagnosis and management were head CT, carotid ultrasound, electroencephalography (EEG), and cardiac enzymes.

EEG had the highest cost per test affecting the diagnosis or management ($32,973), followed by head CT. The cost per test affecting diagnosis or management for postural BP was $17. Cardiac testing, including telemetry, echocardiogram, and cardiac enzymes, had significantly better yield in patients who met SFSR criteria.

Bottom line: In patients with syncope, the history and exam should guide evaluation, and tests with high yield and low cost per test, such as postural BP, should be prioritized.

Citation: Mendu ML, McAvay G, Lampert R, Stoehr J, Tinetti ME. Yield of diagnostic tests in evaluating syncopal episodes in older patients. Arch Intern Med. 2009;169(14): 1299-1305.

 

Early PCI is Superior to Delayed Intervention in Patients with STEMI Receiving Fibrinolytic Therapy

Clinical question: Does early percutaneous coronary intervention (PCI) improve clinical outcomes compared with standard management in patients with ST elevation myocardial infarction (STEMI) who receive fibrinolysis?

Background: Prior research has demonstrated the benefit of timely PCI in the management of acute coronary syndrome, specifically with ST elevation. However, many hospitals do not have this capability and utilize fibrinolysis as a standard alternative. The optimal timing of subsequent invasive intervention following fibrinolysis has not been established.

Study design: Multicenter randomized trial.

Setting: Fifty-two sites in three provinces in Canada.

Synopsis: This study randomized 1,059 patients presenting with STEMI and receiving fibrinolysis to early intervention (immediate transfer to another hospital with PCI less than six hours after fibrinolysis) versus standard intervention (rescue PCI if needed, or delayed angiography at more than 24 hours). The primary outcome was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days.

The primary outcome occurred in 11% of patients in the early intervention group, compared with 17.2% of patients randomized to standard intervention (RR 0.64, 95% CI, 0.47-0.87, P=0.004). Urgent catheterization was performed within 12 hours of fibrinolysis in 34.9% of patients randomized to the standard treatment group.

This study was not powered to detect differences in mortality and other individual components of the primary endpoint.

Bottom line: STEMI patients who received fibrinolysis had a lower risk of adverse outcomes when receiving transfer and PCI within six hours, compared with standard delayed intervention.

Citation: Cantor WJ, Fitchett D, Borgundvaag B, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009;360(26):2705-2718.

 

Specialty Consultation and Limited Access Tests Predict Unsuccessful SSU Admissions

 

Clinical question: In patients admitted to short-stay units (SSUs), what characteristics are associated with unsuccessful SSU admission?

Background: Short-stay units have become prevalent in U.S. hospitals, but it is unclear which patient populations are best served by SSUs.

Study design: Prospective cohort.

Setting: Fourteen-bed SSU in a 500-bed public teaching hospital in Chicago.

Synopsis: More than 700 patients admitted to the Cook County Hospital SSU over a four-month period were interviewed and examined, and their ED and inpatient records were reviewed. An SSU admission was defined as “successful” if the length of stay (LOS) was less than 72 hours and the patient was discharged directly from the SSU.

Overall, 79% of patients had a successful SSU admission. In multivariate analysis, the strongest predictors of an unsuccessful SSU stay were subspecialty consultation (OR 8.1, P<0.001), a provisional diagnosis of heart failure (OR 1.9, P=0.02), and limited availability of a diagnostic test (OR 2.5, P<0.001).

The study was limited primarily to patients with cardiovascular diagnoses.

Bottom line: Patients admitted to SSUs who receive specialty consultation, carry a diagnosis of heart failure, or require diagnostic testing that is not readily available might have a longer LOS or eventual inpatient admission.

Citation: Lucas BP, Kumapley R, Mba B, et al. A hospitalist-run short-stay unit: features that predict length-of-stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276-284.

 

Lack of Significant Gains in Survival Rates Following In-Hospital CPR

Clinical question: Is survival after in-hospital CPR improving over time, and what are the factors associated with survival?

Background: Advances in out-of-hospital CPR have improved outcomes. However, it is unknown whether the survival rate after in-hospital CPR is improving over time, and it is unclear which patient and/or hospital characteristics predict post-CPR survival.

Study design: Retrospective cohort.

Setting: Inpatient Medicare beneficiaries from 1992 to 2005.

Synopsis: The study examined more than 150 million Medicare admissions, 433,985 of which underwent in-hospital CPR. Survival to discharge occurred in 18.3% of CPR events and did not change significantly from 1992 to 2005. The cumulative incidence of in-hospital CPR events was 2.73 per 1,000 admissions; it did not change substantially over time.

The survival rate was lower among black patients (OR 0.76, 95% CI, 0.74-0.79), which is partially explained due to the fact they tended to receive CPR at hospitals with lower post-CPR survival. Gender (specifically male), older age, race (specifically other nonwhite patients), higher burden of chronic illness, and admission from a skilled nursing facility were significantly associated with decreased survival to hospital discharge following CPR.

Limitations of this study included the identification of CPR by ICD-9 codes, which have not been validated for this purpose and could vary among hospitals. Other factors that might explain variations in survival were not available, including severity of acute illness and the presence (or absence) of a shockable rhythm at initial presentation.

Bottom line: Rates of survival to hospital discharge among Medicare beneficiaries receiving in-hospital CPR have remained constant over time, with poorer survival rates among blacks and other nonwhite patients.

Citation: Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.

 

Hospitalists Are Associated with Improved Performance on Quality Metrics

Clinical question: Is the presence of hospitalist physicians associated with improved performance on standard quality measures for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia?

Background: Previous investigations have demonstrated significant improvements in cost and LOS for patients under the care of hospitalists compared with other inpatient providers. The association between hospitalist prevalence and quality of care, as measured by standard quality process measures, is unknown.

 

Study design: Cross-sectional.

Setting: More than 3,600 hospitals participating in the Health Quality Alliance (HQA) program.

Synopsis: Investigators looked at a large sample of HQA hospitals in the American Hospital Association survey, and identified facilities with hospitalist services and those without. The primary endpoint was the adherence to composites of standard quality process measures across three disease categories (AMI, CHF, and pneumonia) and two domains of care (disease treatment/diagnosis and counseling/prevention).

Multivariable analyses revealed a statistically significant association between the presence of hospitalists and adherence to composite quality measures for AMI and pneumonia. This association was demonstrated for both treatment and counseling domains.

The study is cross-sectional, so conclusions cannot be drawn about causality. Also, there are likely unmeasured differences between hospitals that utilize hospitalists compared with those that do not, which could further confound the relationship between the presence of hospitalists and adherence to quality measures.

Finally, this study only evaluated hospital-level performance, and it cannot offer insight on the quality of individual patient care by hospitalist providers.

Bottom line: The presence of hospitalists is associated with improvement in adherence to quality measures for both AMI and pneumonia, and across clinical domains of treatment and counseling.

Citation: López L, Hicks LS, Cohen AP, McKean S, Weissman JS. Hospitalists and the quality of care in hospitals. Arch Intern Med. 2009;169(15):1389-1394. TH

 

New Generics

• Nateglinide (generic Starlix) tablets1

New Drugs, Indications, and Dosage Forms

• Abatacept (Orencia), a selective costimulation modulator used in treating moderate to severe juvenile idiopathic arthritis and rheumatoid arthritis (RA), has undergone a label change regarding earlier use in methotrexate-naïve patients with moderate to severe RA of less than two years’ disease duration.2,3
• Aliskiren/valsartan (Valturna) has been approved by the FDA for treating hypertension in patients with inadequate hypertension control using aliskiren or valsartan alone. It’s also approved for first-line treatment of patients who are likely to need multiple agents to manage their hypertension.4
• Cethromycin (Restanza) has been granted orphan drug approval as a once-daily agent for the prophylaxis of anthrax, tularemia, and the plague. Studies are being conducted on the drug as a potential bioterrorism countermeasure agent through a Department of Defense contract.5
• Ganciclovir ophthalmic gel 0.15% (Zirgan) has been approved by the FDA for treating acute herpetic keratitis. It held orphan drug status for this indication since April 2007. Comparable clinical resolution of herpetic keratitis was obtained compared with acyclovir at day seven in an open-label, multicenter study of 213 patients (77% ganciclovir; 72% acyclovir). The most common adverse effects in clinical trials were blurred vision, eye irritation, punctate keratitis, and conjunctival hyperemia. Dosing recommendations are to instill one drop of ganciclovir in the affected eye five times daily until the ulcer heals, then instill one drop three times daily for seven days. It is anticipated that this product will be available in a 5-g tube in early 2010.6
• Glycerol phenylbutyrate (HPN-100), an experimental intermittent or chronic treatment for patients with cirrhosis and hepatic encephalopathy, has received orphan drug status. A phase-2 trial is planned for late 2009 or early 2010.7 Glycerol phenylbutyrate is a pre-pro-drug of phenylacetic acid, the active component of buphenyl (approved by the FDA to treat urea cycle disorders). Glycerol phenylbutyrate is administered in liquid form and also has orphan drug status for treating urea cycle disorders.
• Guanfacine extended-release tablets (Intuiv), a once-daily, nonstimulant treatment for attention deficit hyperactivity disorder (ADHD), has been approved by the FDA for treating patients 6 to 17 years old. Because guanfacine is not a controlled substance, a 90-day supply can be prescribed.8
• Pancrelipase (Zenpep), a delayed-release pancrelipase enzyme product, has been approved by the FDA for treating adults and children (ages 1 to 12) with cystic fibrosis. The most common adverse effects reported in clinical trials were flatulence, abdominal pain, headache, and cough. The product is available in four prescription strengths: “Eurand 5” is 5,000 USP units of lipase, 17,000 USP units of protease, and 27,000 USP units of amylase; “Eurand 10” is 10,000 units lipase, 34,000 units protease, and 55,000 units amylase; “Eurand 15” is 15,000 units lipase, 51,000 units protease, and 82,000 units amylase; and “Eurand 20” is 20,000 units lipase, 68,000 units protease, and 109,000 units amylase.9,10
• Vigabatrin (Sabril) has been approved by the FDA in an oral solution as monotherapy for treating infantile spasms in children ages one month to 2 years. The tablets also are approved for adjunctive therapy for refractory complex partial seizures in adults who have not adequately responded to other treatments. It is available in 500-mg powder packets for oral solution preparation and 500-mg tablets.11 One severe adverse effect is progressive peripheral vision loss with the potential to decrease visual acuity. Due to this risk of permanent vision loss, vigabatrin is available only through a restricted distribution program.

Pipeline

• Human papillomavirus quadrivalent (Types 6, 11, 16 and 18; Gardasil) has been recommended for approval to prevent genital warts in boys and young men 9 to 26 years old. The FDA is expected to make a decision by the end of 2009.12,13 This vaccine already is approved for use in men in 112 countries.
• Oral insulin (Ora-Lyn) is a proprietary formulation that delivers insulin spray through the buccal mucosa.14 In September, Ora-Lyn was approved under the FDA’s Treatment Investigational New Drug (IND) program for both Type 1 and Type 2 diabetes mellitus. This program allows manufacturers to provide early medication access to investigational drugs for patients with life-threatening or other serious conditions for which there are no satisfactory treatment alternatives. Doctors must register with the IND program to obtain the medication for their patients.15Ora-Lyn already is approved abroad.

 

Drug Information

• On Sept. 22, the FDA banned candy- and fruit-flavored cigarettes under the Family Smoking Prevention and Tobacco Control Act. The goal is to reduce smoking in America.16 Menthol cigarettes and flavored tobacco products are not part of this ban, but they are being evaluated as many of these products are seen as a gateway for children and young adults to begin smoking. More information is available at www.fda.gov/flavoredtobacco. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Par Pharma to begin marketing Starlix generic. Pharmaceutical-Technology.com Web site. Available at: www.pharmaceutical-technology.com/news/news64185.html. Accessed Sept. 23, 2009.
2. Highlights of prescribing information. FDA Web site. Available at: www.accessdata.fda.gov/drugsatfda_docs/label/2009/125118s0086lbl.pdf Accessed Sept. 23, 2009.
3. Bratulic A. Bristol Myers Squibb: Orencia label updated to support earlier use in adults with RA. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=DA78CDE71605485C9BC1B3B40392B1C0&logRowId=323904. Accessed Sept. 23, 2009.
4. Bratulic A. FDA approves Novartis’ Valturna for hypertension. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=4D45881D26B8447D950A4D63E80B806C&logRowId=327307. Accessed Sept. 23, 2009.
5. Advanced Life Sciences’ Restanza could treat plague and anthrax. Pharmaceutical-Technology.com Web site. Available at: www.pharmaceutical-technology.com/News/News64553.html. Accessed Sept. 23, 2009.
6. FDA approves Zirgan. Drugs.com Web site. Available at: www.drugs.com/newdrugs/sirion-therapeutics-announces-fda-approval-zirgan-ganciclovir-ophthalmic-gel-0-15-herpetic-keratitis-1657.html. Accessed Sept. 23, 2009.
7. 7. Hyperion Therapeutics receives orphan drug designation for HPN-100 for the treatment of hepatic encephalopathy. Hyperion Therapeutics Web site. Available at: www.hyperiontx.com/press/release/pr_1253144476. Accessed Sept. 23, 2009.
8. George J. FDA approves nonstimulant Shire ADHD drug. Philadelphia Business Journal Web site. Available at: philadelphia.bizjournals.com/philadelphia/stories/2009/08/31/daily40.html?surround=etf&ana=e_article. Accessed Sept. 23, 2009.
9. Petrochko C. FDA approves first EPI drug for kids. Medpage Today Web site. Available at: www.medpagetoday.com/Gastroenterology/GeneralGastroenterology/15734. Accessed Sept. 23, 2009.
10. Highlights of prescribing information. FDA Web site. Available at: www.accessdata.fda.gov/drugsatfda_docs/label/2009/022210s000lbl.pdf. Accessed Sept. 23, 2009.
11. Sabril approved for infantile spasms and adult epileptic seizures. Monthly Prescribing Reference Web site. Available at: www.empr.com/Sabril-approved-for-infantile-spasms-and-adult-epileptic-seizures/article/147148/. Accessed Sept. 23, 2009.
12. FDA advisory committee recommends approval for use of Gardasil in boys and men. Merck Web site. Available at: www.merck.com/newsroom/press_releases/product/2009_0909.html. Accessed Sept. 23, 2009.
13. Bratulic A. Merck & Co.’s Gardasil recommended by FDA panel for use in boys and men. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=352E8E6109E14925B0168FF465E27C1F&logRowId=325991. Accessed Sept. 23, 2009.
14. Generex technology. Generex Biotechnology Web site. Available at: www.generex.com/technology.php. Accessed Sept. 23, 2009.
15. Reidy C. Generex Drug is OK’d under special FDA program. The Boston Globe Web site. www.generex.com/fckuploads/file/Boston_Globe_09_10_09.pdf. Accessed Sept. 23, 2009.
16. Quinn K. Candy and fruit flavored cigarettes now illegal in United States; step is first under new tobacco law. Food and Drug Administration Web site. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm183211.htm. Accessed Sept. 23, 2009.

New Generics

• Nateglinide (generic Starlix) tablets1

New Drugs, Indications, and Dosage Forms

• Abatacept (Orencia), a selective costimulation modulator used in treating moderate to severe juvenile idiopathic arthritis and rheumatoid arthritis (RA), has undergone a label change regarding earlier use in methotrexate-naïve patients with moderate to severe RA of less than two years’ disease duration.2,3
• Aliskiren/valsartan (Valturna) has been approved by the FDA for treating hypertension in patients with inadequate hypertension control using aliskiren or valsartan alone. It’s also approved for first-line treatment of patients who are likely to need multiple agents to manage their hypertension.4
• Cethromycin (Restanza) has been granted orphan drug approval as a once-daily agent for the prophylaxis of anthrax, tularemia, and the plague. Studies are being conducted on the drug as a potential bioterrorism countermeasure agent through a Department of Defense contract.5
• Ganciclovir ophthalmic gel 0.15% (Zirgan) has been approved by the FDA for treating acute herpetic keratitis. It held orphan drug status for this indication since April 2007. Comparable clinical resolution of herpetic keratitis was obtained compared with acyclovir at day seven in an open-label, multicenter study of 213 patients (77% ganciclovir; 72% acyclovir). The most common adverse effects in clinical trials were blurred vision, eye irritation, punctate keratitis, and conjunctival hyperemia. Dosing recommendations are to instill one drop of ganciclovir in the affected eye five times daily until the ulcer heals, then instill one drop three times daily for seven days. It is anticipated that this product will be available in a 5-g tube in early 2010.6
• Glycerol phenylbutyrate (HPN-100), an experimental intermittent or chronic treatment for patients with cirrhosis and hepatic encephalopathy, has received orphan drug status. A phase-2 trial is planned for late 2009 or early 2010.7 Glycerol phenylbutyrate is a pre-pro-drug of phenylacetic acid, the active component of buphenyl (approved by the FDA to treat urea cycle disorders). Glycerol phenylbutyrate is administered in liquid form and also has orphan drug status for treating urea cycle disorders.
• Guanfacine extended-release tablets (Intuiv), a once-daily, nonstimulant treatment for attention deficit hyperactivity disorder (ADHD), has been approved by the FDA for treating patients 6 to 17 years old. Because guanfacine is not a controlled substance, a 90-day supply can be prescribed.8
• Pancrelipase (Zenpep), a delayed-release pancrelipase enzyme product, has been approved by the FDA for treating adults and children (ages 1 to 12) with cystic fibrosis. The most common adverse effects reported in clinical trials were flatulence, abdominal pain, headache, and cough. The product is available in four prescription strengths: “Eurand 5” is 5,000 USP units of lipase, 17,000 USP units of protease, and 27,000 USP units of amylase; “Eurand 10” is 10,000 units lipase, 34,000 units protease, and 55,000 units amylase; “Eurand 15” is 15,000 units lipase, 51,000 units protease, and 82,000 units amylase; and “Eurand 20” is 20,000 units lipase, 68,000 units protease, and 109,000 units amylase.9,10
• Vigabatrin (Sabril) has been approved by the FDA in an oral solution as monotherapy for treating infantile spasms in children ages one month to 2 years. The tablets also are approved for adjunctive therapy for refractory complex partial seizures in adults who have not adequately responded to other treatments. It is available in 500-mg powder packets for oral solution preparation and 500-mg tablets.11 One severe adverse effect is progressive peripheral vision loss with the potential to decrease visual acuity. Due to this risk of permanent vision loss, vigabatrin is available only through a restricted distribution program.

Pipeline

• Human papillomavirus quadrivalent (Types 6, 11, 16 and 18; Gardasil) has been recommended for approval to prevent genital warts in boys and young men 9 to 26 years old. The FDA is expected to make a decision by the end of 2009.12,13 This vaccine already is approved for use in men in 112 countries.
• Oral insulin (Ora-Lyn) is a proprietary formulation that delivers insulin spray through the buccal mucosa.14 In September, Ora-Lyn was approved under the FDA’s Treatment Investigational New Drug (IND) program for both Type 1 and Type 2 diabetes mellitus. This program allows manufacturers to provide early medication access to investigational drugs for patients with life-threatening or other serious conditions for which there are no satisfactory treatment alternatives. Doctors must register with the IND program to obtain the medication for their patients.15Ora-Lyn already is approved abroad.

 

Drug Information

• On Sept. 22, the FDA banned candy- and fruit-flavored cigarettes under the Family Smoking Prevention and Tobacco Control Act. The goal is to reduce smoking in America.16 Menthol cigarettes and flavored tobacco products are not part of this ban, but they are being evaluated as many of these products are seen as a gateway for children and young adults to begin smoking. More information is available at www.fda.gov/flavoredtobacco. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Par Pharma to begin marketing Starlix generic. Pharmaceutical-Technology.com Web site. Available at: www.pharmaceutical-technology.com/news/news64185.html. Accessed Sept. 23, 2009.
2. Highlights of prescribing information. FDA Web site. Available at: www.accessdata.fda.gov/drugsatfda_docs/label/2009/125118s0086lbl.pdf Accessed Sept. 23, 2009.
3. Bratulic A. Bristol Myers Squibb: Orencia label updated to support earlier use in adults with RA. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=DA78CDE71605485C9BC1B3B40392B1C0&logRowId=323904. Accessed Sept. 23, 2009.
4. Bratulic A. FDA approves Novartis’ Valturna for hypertension. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=4D45881D26B8447D950A4D63E80B806C&logRowId=327307. Accessed Sept. 23, 2009.
5. Advanced Life Sciences’ Restanza could treat plague and anthrax. Pharmaceutical-Technology.com Web site. Available at: www.pharmaceutical-technology.com/News/News64553.html. Accessed Sept. 23, 2009.
6. FDA approves Zirgan. Drugs.com Web site. Available at: www.drugs.com/newdrugs/sirion-therapeutics-announces-fda-approval-zirgan-ganciclovir-ophthalmic-gel-0-15-herpetic-keratitis-1657.html. Accessed Sept. 23, 2009.
7. 7. Hyperion Therapeutics receives orphan drug designation for HPN-100 for the treatment of hepatic encephalopathy. Hyperion Therapeutics Web site. Available at: www.hyperiontx.com/press/release/pr_1253144476. Accessed Sept. 23, 2009.
8. George J. FDA approves nonstimulant Shire ADHD drug. Philadelphia Business Journal Web site. Available at: philadelphia.bizjournals.com/philadelphia/stories/2009/08/31/daily40.html?surround=etf&ana=e_article. Accessed Sept. 23, 2009.
9. Petrochko C. FDA approves first EPI drug for kids. Medpage Today Web site. Available at: www.medpagetoday.com/Gastroenterology/GeneralGastroenterology/15734. Accessed Sept. 23, 2009.
10. Highlights of prescribing information. FDA Web site. Available at: www.accessdata.fda.gov/drugsatfda_docs/label/2009/022210s000lbl.pdf. Accessed Sept. 23, 2009.
11. Sabril approved for infantile spasms and adult epileptic seizures. Monthly Prescribing Reference Web site. Available at: www.empr.com/Sabril-approved-for-infantile-spasms-and-adult-epileptic-seizures/article/147148/. Accessed Sept. 23, 2009.
12. FDA advisory committee recommends approval for use of Gardasil in boys and men. Merck Web site. Available at: www.merck.com/newsroom/press_releases/product/2009_0909.html. Accessed Sept. 23, 2009.
13. Bratulic A. Merck & Co.’s Gardasil recommended by FDA panel for use in boys and men. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=352E8E6109E14925B0168FF465E27C1F&logRowId=325991. Accessed Sept. 23, 2009.
14. Generex technology. Generex Biotechnology Web site. Available at: www.generex.com/technology.php. Accessed Sept. 23, 2009.
15. Reidy C. Generex Drug is OK’d under special FDA program. The Boston Globe Web site. www.generex.com/fckuploads/file/Boston_Globe_09_10_09.pdf. Accessed Sept. 23, 2009.
16. Quinn K. Candy and fruit flavored cigarettes now illegal in United States; step is first under new tobacco law. Food and Drug Administration Web site. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm183211.htm. Accessed Sept. 23, 2009.

New Generics

• Nateglinide (generic Starlix) tablets1

New Drugs, Indications, and Dosage Forms

• Abatacept (Orencia), a selective costimulation modulator used in treating moderate to severe juvenile idiopathic arthritis and rheumatoid arthritis (RA), has undergone a label change regarding earlier use in methotrexate-naïve patients with moderate to severe RA of less than two years’ disease duration.2,3
• Aliskiren/valsartan (Valturna) has been approved by the FDA for treating hypertension in patients with inadequate hypertension control using aliskiren or valsartan alone. It’s also approved for first-line treatment of patients who are likely to need multiple agents to manage their hypertension.4
• Cethromycin (Restanza) has been granted orphan drug approval as a once-daily agent for the prophylaxis of anthrax, tularemia, and the plague. Studies are being conducted on the drug as a potential bioterrorism countermeasure agent through a Department of Defense contract.5
• Ganciclovir ophthalmic gel 0.15% (Zirgan) has been approved by the FDA for treating acute herpetic keratitis. It held orphan drug status for this indication since April 2007. Comparable clinical resolution of herpetic keratitis was obtained compared with acyclovir at day seven in an open-label, multicenter study of 213 patients (77% ganciclovir; 72% acyclovir). The most common adverse effects in clinical trials were blurred vision, eye irritation, punctate keratitis, and conjunctival hyperemia. Dosing recommendations are to instill one drop of ganciclovir in the affected eye five times daily until the ulcer heals, then instill one drop three times daily for seven days. It is anticipated that this product will be available in a 5-g tube in early 2010.6
• Glycerol phenylbutyrate (HPN-100), an experimental intermittent or chronic treatment for patients with cirrhosis and hepatic encephalopathy, has received orphan drug status. A phase-2 trial is planned for late 2009 or early 2010.7 Glycerol phenylbutyrate is a pre-pro-drug of phenylacetic acid, the active component of buphenyl (approved by the FDA to treat urea cycle disorders). Glycerol phenylbutyrate is administered in liquid form and also has orphan drug status for treating urea cycle disorders.
• Guanfacine extended-release tablets (Intuiv), a once-daily, nonstimulant treatment for attention deficit hyperactivity disorder (ADHD), has been approved by the FDA for treating patients 6 to 17 years old. Because guanfacine is not a controlled substance, a 90-day supply can be prescribed.8
• Pancrelipase (Zenpep), a delayed-release pancrelipase enzyme product, has been approved by the FDA for treating adults and children (ages 1 to 12) with cystic fibrosis. The most common adverse effects reported in clinical trials were flatulence, abdominal pain, headache, and cough. The product is available in four prescription strengths: “Eurand 5” is 5,000 USP units of lipase, 17,000 USP units of protease, and 27,000 USP units of amylase; “Eurand 10” is 10,000 units lipase, 34,000 units protease, and 55,000 units amylase; “Eurand 15” is 15,000 units lipase, 51,000 units protease, and 82,000 units amylase; and “Eurand 20” is 20,000 units lipase, 68,000 units protease, and 109,000 units amylase.9,10
• Vigabatrin (Sabril) has been approved by the FDA in an oral solution as monotherapy for treating infantile spasms in children ages one month to 2 years. The tablets also are approved for adjunctive therapy for refractory complex partial seizures in adults who have not adequately responded to other treatments. It is available in 500-mg powder packets for oral solution preparation and 500-mg tablets.11 One severe adverse effect is progressive peripheral vision loss with the potential to decrease visual acuity. Due to this risk of permanent vision loss, vigabatrin is available only through a restricted distribution program.

Pipeline

• Human papillomavirus quadrivalent (Types 6, 11, 16 and 18; Gardasil) has been recommended for approval to prevent genital warts in boys and young men 9 to 26 years old. The FDA is expected to make a decision by the end of 2009.12,13 This vaccine already is approved for use in men in 112 countries.
• Oral insulin (Ora-Lyn) is a proprietary formulation that delivers insulin spray through the buccal mucosa.14 In September, Ora-Lyn was approved under the FDA’s Treatment Investigational New Drug (IND) program for both Type 1 and Type 2 diabetes mellitus. This program allows manufacturers to provide early medication access to investigational drugs for patients with life-threatening or other serious conditions for which there are no satisfactory treatment alternatives. Doctors must register with the IND program to obtain the medication for their patients.15Ora-Lyn already is approved abroad.

 

Drug Information

• On Sept. 22, the FDA banned candy- and fruit-flavored cigarettes under the Family Smoking Prevention and Tobacco Control Act. The goal is to reduce smoking in America.16 Menthol cigarettes and flavored tobacco products are not part of this ban, but they are being evaluated as many of these products are seen as a gateway for children and young adults to begin smoking. More information is available at www.fda.gov/flavoredtobacco. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City and a clinical pharmacist at New York Downtown Hospital.

References

1. Par Pharma to begin marketing Starlix generic. Pharmaceutical-Technology.com Web site. Available at: www.pharmaceutical-technology.com/news/news64185.html. Accessed Sept. 23, 2009.
2. Highlights of prescribing information. FDA Web site. Available at: www.accessdata.fda.gov/drugsatfda_docs/label/2009/125118s0086lbl.pdf Accessed Sept. 23, 2009.
3. Bratulic A. Bristol Myers Squibb: Orencia label updated to support earlier use in adults with RA. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=DA78CDE71605485C9BC1B3B40392B1C0&logRowId=323904. Accessed Sept. 23, 2009.
4. Bratulic A. FDA approves Novartis’ Valturna for hypertension. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=4D45881D26B8447D950A4D63E80B806C&logRowId=327307. Accessed Sept. 23, 2009.
5. Advanced Life Sciences’ Restanza could treat plague and anthrax. Pharmaceutical-Technology.com Web site. Available at: www.pharmaceutical-technology.com/News/News64553.html. Accessed Sept. 23, 2009.
6. FDA approves Zirgan. Drugs.com Web site. Available at: www.drugs.com/newdrugs/sirion-therapeutics-announces-fda-approval-zirgan-ganciclovir-ophthalmic-gel-0-15-herpetic-keratitis-1657.html. Accessed Sept. 23, 2009.
7. 7. Hyperion Therapeutics receives orphan drug designation for HPN-100 for the treatment of hepatic encephalopathy. Hyperion Therapeutics Web site. Available at: www.hyperiontx.com/press/release/pr_1253144476. Accessed Sept. 23, 2009.
8. George J. FDA approves nonstimulant Shire ADHD drug. Philadelphia Business Journal Web site. Available at: philadelphia.bizjournals.com/philadelphia/stories/2009/08/31/daily40.html?surround=etf&ana=e_article. Accessed Sept. 23, 2009.
9. Petrochko C. FDA approves first EPI drug for kids. Medpage Today Web site. Available at: www.medpagetoday.com/Gastroenterology/GeneralGastroenterology/15734. Accessed Sept. 23, 2009.
10. Highlights of prescribing information. FDA Web site. Available at: www.accessdata.fda.gov/drugsatfda_docs/label/2009/022210s000lbl.pdf. Accessed Sept. 23, 2009.
11. Sabril approved for infantile spasms and adult epileptic seizures. Monthly Prescribing Reference Web site. Available at: www.empr.com/Sabril-approved-for-infantile-spasms-and-adult-epileptic-seizures/article/147148/. Accessed Sept. 23, 2009.
12. FDA advisory committee recommends approval for use of Gardasil in boys and men. Merck Web site. Available at: www.merck.com/newsroom/press_releases/product/2009_0909.html. Accessed Sept. 23, 2009.
13. Bratulic A. Merck & Co.’s Gardasil recommended by FDA panel for use in boys and men. FirstWord Web site. Available at: www.firstwordplus.com/Fws.do?articleid=352E8E6109E14925B0168FF465E27C1F&logRowId=325991. Accessed Sept. 23, 2009.
14. Generex technology. Generex Biotechnology Web site. Available at: www.generex.com/technology.php. Accessed Sept. 23, 2009.
15. Reidy C. Generex Drug is OK’d under special FDA program. The Boston Globe Web site. www.generex.com/fckuploads/file/Boston_Globe_09_10_09.pdf. Accessed Sept. 23, 2009.
16. Quinn K. Candy and fruit flavored cigarettes now illegal in United States; step is first under new tobacco law. Food and Drug Administration Web site. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm183211.htm. Accessed Sept. 23, 2009.

As hospitalists take on more demanding leadership roles, the climb up the career ladder evolves into a juggling act: Hospitalists typically try to handle a full patient load as well as new administrative duties.

If a hospitalist continues to ascend, those administrative duties can begin to consume the schedule. The individual—and the group—could face important decisions about priorities, schedules, and money.

“Hospital medicine is only ten years old; we’re still trying to figure this out,” says Mary Jo Gorman, MD, MBA, chief executive officer of Advanced ICU Care in St. Louis and a past president of SHM. “It’s always a challenge. You identify that you have a need for someone to take charge of an administrative task, but it can take as long as a year to free up [the hospitalist’s] time so that it can get done.”

If you have found yourself in this position, you know that something has to give. “I’ve seen high-energy physicians who think that they can do it all—and they had to,” says Joan C. Faro, MD, FACP, MBA, chief medical officer at John T. Mather Memorial Hospital in Port Jefferson, N.Y. “That is not sustainable. It can’t last forever.”

The question is, how can a hospitalist effectively balance their clinical and administrative duties? Furthermore, what happens when the scales tip in favor—and to the detriment—of one or the other?

When the Juggling Begins

Hospitalists usually add “extra” duties to their normal workloads to advance their careers. Few relinquish their clinical duties as they join committees, further their training, lead a research project, or take on administrative duties.

Dr. Faro says a hospitalist should be able to “head up a focused project or serve on committees” and still be able to meet all their clinical duties. “Once you get beyond that, you need a certain amount of protected time” for administrative or project work, she says. “And when you start to have people reporting to you, you absolutely need that protected time.”

Assigning administrative tasks to physicians who regularly see patients depends on the group structure and requires a clearly defined job description. “If a group is really going to make this work, then you have to pay people for that extra time,” Dr. Gorman says.

Ideally, HM groups have job descriptions for physicians who are called upon to see patients and handle administrative duties. Contracts should include specifications for “protected time,” as well as compensation for new responsibilities.

Clinical-Hour Cutbacks

As administrative duties grow, something has to give. Hospitalists who want to pursue positions of leadership know that that something is hours spent delivering patient care. “If you’re a hospitalist-administrator who wants to make the leap to vice president or department chair or chief medical officer, you need to devote a lot of time to your administrative work,” Dr. Faro says. “You can’t make that leap without putting in those hours.”

So what is a reasonable division of time for, say, the director of an HM program or department? “It’s impossible to pinpoint, but I’d say roughly that [a director] should spend not less than 25% or 30% of their time, and certainly not more than 50% of their time, on clinical work,” Dr. Faro estimates.

 

Even upper-level physician-administrators should maintain a clinical practice simply to monitor the work their department is doing. “It’s not about [clinical] skills as much as it is about whether you can relate to physicians’ day-to-day work, to their frustrations,” Dr. Gorman says. “That’s a management challenge no matter who you are. For example, if hospitalists are complaining about a new EMR [electronic medical record] system, are you going to say, ‘Oh, just put up with it; it’s not that bad. It will be fine’? Or are you out there trying it and saying, ‘Holy cow, this is really inefficient. We have to change this’?”

On the flip side, how much time should be devoted to administrative tasks? The answer depends on the size of your program and the amount of work you have to do, Dr. Faro says. Group directors and department heads normally make themselves available during regular weekday hours. That usually means you’ll have to fit in your clinical work around meetings, budgets, and presentations.

Can You Give Up Clinical Duties?

It’s natural for physicians to be reluctant to relinquish patient care; some reach a point where they have to make the tough decision to stop clinical work altogether.

“You may figure out that you want to pursue an administrative role, but you don’t want to give up clinical work,” says Dr. Gorman, who spent 15 years juggling a full clinical schedule with administrative duties before she became a full-time administrator. “You get plenty of opportunities to make that decision as you’re crossing back and forth.”

You might want to evaluate your options and make the choice sooner rather than later. Once you’re in administration, the decision might be forced upon you. “Eventually, you’ll find that critical things are happening all hours of the day, any given day of the week, in administration as well as clinical practice,” Dr. Faro says. “There’s a point at which you realize that part-time [administrative work] just doesn’t work. You realize that your expertise and guidance are needed.”

Dr. Gorman warns that there are risks and changes involved with becoming a full-time administrator. Once you decide to give up your clinical practice and go the leadership route, your career is “in the hands of someone else,” she points out. “Your position could be eliminated. You could be fired or replaced. … That is a concern. A lot of people keep their hand in on clinical skills for that reason.” You also might find that advancing a management career requires moving to a new organization or a different part of the country.

On the other hand, the rewards of a career in administration can’t be overlooked. “It’s very satisfying personally,” Dr. Faro says. “It’s inventive; you’re constantly solving problems that didn’t exist yesterday.

 

“It’s a different kind of job satisfaction. It’s a very personal decision. There are people who realize that this just isn’t for them.” TH

Jane Jerrard is a freelance writer based in Chicago.

As hospitalists take on more demanding leadership roles, the climb up the career ladder evolves into a juggling act: Hospitalists typically try to handle a full patient load as well as new administrative duties.

If a hospitalist continues to ascend, those administrative duties can begin to consume the schedule. The individual—and the group—could face important decisions about priorities, schedules, and money.

“Hospital medicine is only ten years old; we’re still trying to figure this out,” says Mary Jo Gorman, MD, MBA, chief executive officer of Advanced ICU Care in St. Louis and a past president of SHM. “It’s always a challenge. You identify that you have a need for someone to take charge of an administrative task, but it can take as long as a year to free up [the hospitalist’s] time so that it can get done.”

If you have found yourself in this position, you know that something has to give. “I’ve seen high-energy physicians who think that they can do it all—and they had to,” says Joan C. Faro, MD, FACP, MBA, chief medical officer at John T. Mather Memorial Hospital in Port Jefferson, N.Y. “That is not sustainable. It can’t last forever.”

The question is, how can a hospitalist effectively balance their clinical and administrative duties? Furthermore, what happens when the scales tip in favor—and to the detriment—of one or the other?

When the Juggling Begins

Hospitalists usually add “extra” duties to their normal workloads to advance their careers. Few relinquish their clinical duties as they join committees, further their training, lead a research project, or take on administrative duties.

Dr. Faro says a hospitalist should be able to “head up a focused project or serve on committees” and still be able to meet all their clinical duties. “Once you get beyond that, you need a certain amount of protected time” for administrative or project work, she says. “And when you start to have people reporting to you, you absolutely need that protected time.”

Assigning administrative tasks to physicians who regularly see patients depends on the group structure and requires a clearly defined job description. “If a group is really going to make this work, then you have to pay people for that extra time,” Dr. Gorman says.

Ideally, HM groups have job descriptions for physicians who are called upon to see patients and handle administrative duties. Contracts should include specifications for “protected time,” as well as compensation for new responsibilities.

Clinical-Hour Cutbacks

As administrative duties grow, something has to give. Hospitalists who want to pursue positions of leadership know that that something is hours spent delivering patient care. “If you’re a hospitalist-administrator who wants to make the leap to vice president or department chair or chief medical officer, you need to devote a lot of time to your administrative work,” Dr. Faro says. “You can’t make that leap without putting in those hours.”

So what is a reasonable division of time for, say, the director of an HM program or department? “It’s impossible to pinpoint, but I’d say roughly that [a director] should spend not less than 25% or 30% of their time, and certainly not more than 50% of their time, on clinical work,” Dr. Faro estimates.

 

Even upper-level physician-administrators should maintain a clinical practice simply to monitor the work their department is doing. “It’s not about [clinical] skills as much as it is about whether you can relate to physicians’ day-to-day work, to their frustrations,” Dr. Gorman says. “That’s a management challenge no matter who you are. For example, if hospitalists are complaining about a new EMR [electronic medical record] system, are you going to say, ‘Oh, just put up with it; it’s not that bad. It will be fine’? Or are you out there trying it and saying, ‘Holy cow, this is really inefficient. We have to change this’?”

On the flip side, how much time should be devoted to administrative tasks? The answer depends on the size of your program and the amount of work you have to do, Dr. Faro says. Group directors and department heads normally make themselves available during regular weekday hours. That usually means you’ll have to fit in your clinical work around meetings, budgets, and presentations.

Can You Give Up Clinical Duties?

It’s natural for physicians to be reluctant to relinquish patient care; some reach a point where they have to make the tough decision to stop clinical work altogether.

“You may figure out that you want to pursue an administrative role, but you don’t want to give up clinical work,” says Dr. Gorman, who spent 15 years juggling a full clinical schedule with administrative duties before she became a full-time administrator. “You get plenty of opportunities to make that decision as you’re crossing back and forth.”

You might want to evaluate your options and make the choice sooner rather than later. Once you’re in administration, the decision might be forced upon you. “Eventually, you’ll find that critical things are happening all hours of the day, any given day of the week, in administration as well as clinical practice,” Dr. Faro says. “There’s a point at which you realize that part-time [administrative work] just doesn’t work. You realize that your expertise and guidance are needed.”

Dr. Gorman warns that there are risks and changes involved with becoming a full-time administrator. Once you decide to give up your clinical practice and go the leadership route, your career is “in the hands of someone else,” she points out. “Your position could be eliminated. You could be fired or replaced. … That is a concern. A lot of people keep their hand in on clinical skills for that reason.” You also might find that advancing a management career requires moving to a new organization or a different part of the country.

On the other hand, the rewards of a career in administration can’t be overlooked. “It’s very satisfying personally,” Dr. Faro says. “It’s inventive; you’re constantly solving problems that didn’t exist yesterday.

 

“It’s a different kind of job satisfaction. It’s a very personal decision. There are people who realize that this just isn’t for them.” TH

Jane Jerrard is a freelance writer based in Chicago.

As hospitalists take on more demanding leadership roles, the climb up the career ladder evolves into a juggling act: Hospitalists typically try to handle a full patient load as well as new administrative duties.

If a hospitalist continues to ascend, those administrative duties can begin to consume the schedule. The individual—and the group—could face important decisions about priorities, schedules, and money.

“Hospital medicine is only ten years old; we’re still trying to figure this out,” says Mary Jo Gorman, MD, MBA, chief executive officer of Advanced ICU Care in St. Louis and a past president of SHM. “It’s always a challenge. You identify that you have a need for someone to take charge of an administrative task, but it can take as long as a year to free up [the hospitalist’s] time so that it can get done.”

If you have found yourself in this position, you know that something has to give. “I’ve seen high-energy physicians who think that they can do it all—and they had to,” says Joan C. Faro, MD, FACP, MBA, chief medical officer at John T. Mather Memorial Hospital in Port Jefferson, N.Y. “That is not sustainable. It can’t last forever.”

The question is, how can a hospitalist effectively balance their clinical and administrative duties? Furthermore, what happens when the scales tip in favor—and to the detriment—of one or the other?

When the Juggling Begins

Hospitalists usually add “extra” duties to their normal workloads to advance their careers. Few relinquish their clinical duties as they join committees, further their training, lead a research project, or take on administrative duties.

Dr. Faro says a hospitalist should be able to “head up a focused project or serve on committees” and still be able to meet all their clinical duties. “Once you get beyond that, you need a certain amount of protected time” for administrative or project work, she says. “And when you start to have people reporting to you, you absolutely need that protected time.”

Assigning administrative tasks to physicians who regularly see patients depends on the group structure and requires a clearly defined job description. “If a group is really going to make this work, then you have to pay people for that extra time,” Dr. Gorman says.

Ideally, HM groups have job descriptions for physicians who are called upon to see patients and handle administrative duties. Contracts should include specifications for “protected time,” as well as compensation for new responsibilities.

Clinical-Hour Cutbacks

As administrative duties grow, something has to give. Hospitalists who want to pursue positions of leadership know that that something is hours spent delivering patient care. “If you’re a hospitalist-administrator who wants to make the leap to vice president or department chair or chief medical officer, you need to devote a lot of time to your administrative work,” Dr. Faro says. “You can’t make that leap without putting in those hours.”

So what is a reasonable division of time for, say, the director of an HM program or department? “It’s impossible to pinpoint, but I’d say roughly that [a director] should spend not less than 25% or 30% of their time, and certainly not more than 50% of their time, on clinical work,” Dr. Faro estimates.

 

Even upper-level physician-administrators should maintain a clinical practice simply to monitor the work their department is doing. “It’s not about [clinical] skills as much as it is about whether you can relate to physicians’ day-to-day work, to their frustrations,” Dr. Gorman says. “That’s a management challenge no matter who you are. For example, if hospitalists are complaining about a new EMR [electronic medical record] system, are you going to say, ‘Oh, just put up with it; it’s not that bad. It will be fine’? Or are you out there trying it and saying, ‘Holy cow, this is really inefficient. We have to change this’?”

On the flip side, how much time should be devoted to administrative tasks? The answer depends on the size of your program and the amount of work you have to do, Dr. Faro says. Group directors and department heads normally make themselves available during regular weekday hours. That usually means you’ll have to fit in your clinical work around meetings, budgets, and presentations.

Can You Give Up Clinical Duties?

It’s natural for physicians to be reluctant to relinquish patient care; some reach a point where they have to make the tough decision to stop clinical work altogether.

“You may figure out that you want to pursue an administrative role, but you don’t want to give up clinical work,” says Dr. Gorman, who spent 15 years juggling a full clinical schedule with administrative duties before she became a full-time administrator. “You get plenty of opportunities to make that decision as you’re crossing back and forth.”

You might want to evaluate your options and make the choice sooner rather than later. Once you’re in administration, the decision might be forced upon you. “Eventually, you’ll find that critical things are happening all hours of the day, any given day of the week, in administration as well as clinical practice,” Dr. Faro says. “There’s a point at which you realize that part-time [administrative work] just doesn’t work. You realize that your expertise and guidance are needed.”

Dr. Gorman warns that there are risks and changes involved with becoming a full-time administrator. Once you decide to give up your clinical practice and go the leadership route, your career is “in the hands of someone else,” she points out. “Your position could be eliminated. You could be fired or replaced. … That is a concern. A lot of people keep their hand in on clinical skills for that reason.” You also might find that advancing a management career requires moving to a new organization or a different part of the country.

On the other hand, the rewards of a career in administration can’t be overlooked. “It’s very satisfying personally,” Dr. Faro says. “It’s inventive; you’re constantly solving problems that didn’t exist yesterday.

 

“It’s a different kind of job satisfaction. It’s a very personal decision. There are people who realize that this just isn’t for them.” TH

Jane Jerrard is a freelance writer based in Chicago.

In his June 2009 address to the American Medical Association, President Obama commented that “doctors feel like they are constantly looking over their shoulder for fear of lawsuits. Some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable.”¹ By practicing what the President called “excessive defensive medicine,” doctors provide “more treatment rather than better care” and drive up the cost of health care ( Box ).^2-7

This column takes a look at how defensive practices can make psychiatric care more costly and less effective, by answering these questions:

• What is defensive medicine?
• How much medical practice is “defensive,” and what does it cost?
• Do psychiatrists practice defensive medicine?
• Does defensive psychiatric practice lead to suboptimal care?
• Are some defensive practices justified?
• Can you balance good defense with good care?

What is defensive medicine?

In a 1994 study, the U.S. Office of Technology Assessment (OTA) said that defensive medicine occurs “when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily or solely) to reduce their exposure to malpractice liability.” This definition does not require that defensive clinical practices provide no benefit to patients, only that the expected benefits are small relative to their costs.⁸

Preventing the worst outcome

Studies suggest that doctors develop and maintain practice habits—consciously or not—that aim to reduce their risk of getting sued for malpractice. For example, when patients presenting with tick bites express concern about Lyme disease, doctors overuse tests and needlessly prescribe antibiotics.⁹ Although these practices are not evidence-based, they reduce doctors’ anxiety by “preventing the worst outcome at relatively little risk and cost and avoiding a potential lawsuit at the same time.”¹⁰

The OTA estimated that up to 8% of diagnostic procedures were ordered primarily because of conscious concern about malpractice liability, based on physicians’ responses to a set of written scenarios.⁸ In a recent study, 83% of Massachusetts physicians reported practicing defensive medicine and estimated that defensive reasons accounted for why they ordered:

• 18% of lab tests
• up to 30% of procedures and consultations
• 13% of hospitalizations.¹¹

Almost all high-liability specialists (such as emergency room physicians, surgeons, and obstetrician/gynecologists) report practicing defensive medicine, often gaging in “assurance behavior”—ordering tests, doing diagnostic procedures, and referring patients to consultants.¹²

Defensive psychiatry

Compared with other specialists, psychiatrists are at lower risk for being sued, but we engage in defensive practices nonetheless. A survey of British psychiatrists found that during the previous month, 75% made clinical decisions—such as “overcautiously” admitting patients or ordering special observation—because of worries about possible legal claims, complaints, or disciplinary action.¹³

Younger psychiatrists and psychiatrists who have experienced complaints and critical incidents are more likely to practice defensive medicine. This is hardly surprising—a malpractice suit can be very stressful.¹⁴ But an amorphous dread of lawsuits affects many psychiatrists, including residents who never have been sued. The result: many needless, countertherapeutic, defensive practices.^15,16

Unintended consequences

Defensive medicine is not just expensive and wasteful. It could increase your risk of litigation if practices result in harm.¹⁷ Simon and Shuman¹⁶ give examples of how attempts to avoid litigation can compromise clinical care when treating patients at risk for suicide:

• not prescribing clozapine—a treatment known to lower the risk of suicide¹⁸ —to a chronically suicidal patient with schizophrenia because of fears of agranulocytosis (see “Clozapine for schizophrenia: Life-threatening or life-saving treatment?” Current Psychiatry, December 2009)
• not recommending electroconvulsive therapy—and possibly prolonging the period when a severely depressed patient is at high risk for suicide—to avoid a lawsuit related to memory loss
• hospitalizing a patient at chronic risk for suicide who could be managed as an outpatient with appropriate safeguards, a practice that could undermine a valuable treatment alliance.

 

Good clinical care lowers the likelihood of harm to patients, making it a sound risk management practice, though not a complete strategy. Even the best doctors can start to think defensively when confronted with awkward, troubling, or life-threatening situations that could have medicolegal implications.¹⁶ For example, when an outpatient threatens to hurt someone else, it may be tempting to just confine him in a hospital (which reduces the doctor’s anxiety) even when other less coercive and more therapeutic options might better resolve the patient’s problems and the risk of violence.

Recognizing that you’re making clinical decisions out of fear of getting sued is the first step toward curtailing needlessly defensive practice. See Table ¹⁹ for more strategies.

Table

3 strategies for avoiding needless defensive medicine

Ask yourself, “If I weren’t worried about getting sued, what would I do?” or “If I were my patient, what would I want me to do?” These questions, which help you identify the best clinical response, also may help you to implement it without taking extraneous defensive measures.
“Never worry alone.” This recommendation from the Massachusetts General Hospital and McLean Hospital training programs19 means that if you’re concerned about a case, ask a colleague for a consultation. In addition to being helpful and reassuring, an outside perspective can support nondefensive, patient-oriented decision making.
If the treatment course you think is best involves a legal matter, make sure you understand the legal issues. For example, civil commitment is often the right intervention for a mentally ill person who poses a serious risk of harm, but some patients threaten to sue doctors who propose involuntary hospitalization. Your hospital’s attorney may provide explanation and legal guidance if you do not thoroughly understand legal mechanisms or whether you are properly invoking them

Justifiable defensiveness

Of course, it’s perfectly appropriate for psychiatrists to recognize malpractice risks and take appropriate measures to avoid successful lawsuits. For example, thoughtful documentation of your data gathering, decision making, and informed consent is an appropriate protective practice. Usually, no one sees the documentation, and it contributes little to your patients’ well-being. Good documentation can be inexpensive, however, and if done creatively, can improve data recording that in turn contributes to better treatment.²⁰

In his June 2009 address to the American Medical Association, President Obama commented that “doctors feel like they are constantly looking over their shoulder for fear of lawsuits. Some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable.”¹ By practicing what the President called “excessive defensive medicine,” doctors provide “more treatment rather than better care” and drive up the cost of health care ( Box ).^2-7

This column takes a look at how defensive practices can make psychiatric care more costly and less effective, by answering these questions:

• What is defensive medicine?
• How much medical practice is “defensive,” and what does it cost?
• Do psychiatrists practice defensive medicine?
• Does defensive psychiatric practice lead to suboptimal care?
• Are some defensive practices justified?
• Can you balance good defense with good care?

What is defensive medicine?

In a 1994 study, the U.S. Office of Technology Assessment (OTA) said that defensive medicine occurs “when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily or solely) to reduce their exposure to malpractice liability.” This definition does not require that defensive clinical practices provide no benefit to patients, only that the expected benefits are small relative to their costs.⁸

Preventing the worst outcome

Studies suggest that doctors develop and maintain practice habits—consciously or not—that aim to reduce their risk of getting sued for malpractice. For example, when patients presenting with tick bites express concern about Lyme disease, doctors overuse tests and needlessly prescribe antibiotics.⁹ Although these practices are not evidence-based, they reduce doctors’ anxiety by “preventing the worst outcome at relatively little risk and cost and avoiding a potential lawsuit at the same time.”¹⁰

The OTA estimated that up to 8% of diagnostic procedures were ordered primarily because of conscious concern about malpractice liability, based on physicians’ responses to a set of written scenarios.⁸ In a recent study, 83% of Massachusetts physicians reported practicing defensive medicine and estimated that defensive reasons accounted for why they ordered:

• 18% of lab tests
• up to 30% of procedures and consultations
• 13% of hospitalizations.¹¹

Almost all high-liability specialists (such as emergency room physicians, surgeons, and obstetrician/gynecologists) report practicing defensive medicine, often gaging in “assurance behavior”—ordering tests, doing diagnostic procedures, and referring patients to consultants.¹²

Defensive psychiatry

Compared with other specialists, psychiatrists are at lower risk for being sued, but we engage in defensive practices nonetheless. A survey of British psychiatrists found that during the previous month, 75% made clinical decisions—such as “overcautiously” admitting patients or ordering special observation—because of worries about possible legal claims, complaints, or disciplinary action.¹³

Younger psychiatrists and psychiatrists who have experienced complaints and critical incidents are more likely to practice defensive medicine. This is hardly surprising—a malpractice suit can be very stressful.¹⁴ But an amorphous dread of lawsuits affects many psychiatrists, including residents who never have been sued. The result: many needless, countertherapeutic, defensive practices.^15,16

Unintended consequences

Defensive medicine is not just expensive and wasteful. It could increase your risk of litigation if practices result in harm.¹⁷ Simon and Shuman¹⁶ give examples of how attempts to avoid litigation can compromise clinical care when treating patients at risk for suicide:

• not prescribing clozapine—a treatment known to lower the risk of suicide¹⁸ —to a chronically suicidal patient with schizophrenia because of fears of agranulocytosis (see “Clozapine for schizophrenia: Life-threatening or life-saving treatment?” Current Psychiatry, December 2009)
• not recommending electroconvulsive therapy—and possibly prolonging the period when a severely depressed patient is at high risk for suicide—to avoid a lawsuit related to memory loss
• hospitalizing a patient at chronic risk for suicide who could be managed as an outpatient with appropriate safeguards, a practice that could undermine a valuable treatment alliance.

 

Good clinical care lowers the likelihood of harm to patients, making it a sound risk management practice, though not a complete strategy. Even the best doctors can start to think defensively when confronted with awkward, troubling, or life-threatening situations that could have medicolegal implications.¹⁶ For example, when an outpatient threatens to hurt someone else, it may be tempting to just confine him in a hospital (which reduces the doctor’s anxiety) even when other less coercive and more therapeutic options might better resolve the patient’s problems and the risk of violence.

Recognizing that you’re making clinical decisions out of fear of getting sued is the first step toward curtailing needlessly defensive practice. See Table ¹⁹ for more strategies.

Table

3 strategies for avoiding needless defensive medicine

Ask yourself, “If I weren’t worried about getting sued, what would I do?” or “If I were my patient, what would I want me to do?” These questions, which help you identify the best clinical response, also may help you to implement it without taking extraneous defensive measures.
“Never worry alone.” This recommendation from the Massachusetts General Hospital and McLean Hospital training programs19 means that if you’re concerned about a case, ask a colleague for a consultation. In addition to being helpful and reassuring, an outside perspective can support nondefensive, patient-oriented decision making.
If the treatment course you think is best involves a legal matter, make sure you understand the legal issues. For example, civil commitment is often the right intervention for a mentally ill person who poses a serious risk of harm, but some patients threaten to sue doctors who propose involuntary hospitalization. Your hospital’s attorney may provide explanation and legal guidance if you do not thoroughly understand legal mechanisms or whether you are properly invoking them

Justifiable defensiveness

Of course, it’s perfectly appropriate for psychiatrists to recognize malpractice risks and take appropriate measures to avoid successful lawsuits. For example, thoughtful documentation of your data gathering, decision making, and informed consent is an appropriate protective practice. Usually, no one sees the documentation, and it contributes little to your patients’ well-being. Good documentation can be inexpensive, however, and if done creatively, can improve data recording that in turn contributes to better treatment.²⁰

In his June 2009 address to the American Medical Association, President Obama commented that “doctors feel like they are constantly looking over their shoulder for fear of lawsuits. Some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable.”¹ By practicing what the President called “excessive defensive medicine,” doctors provide “more treatment rather than better care” and drive up the cost of health care ( Box ).^2-7

This column takes a look at how defensive practices can make psychiatric care more costly and less effective, by answering these questions:

• What is defensive medicine?
• How much medical practice is “defensive,” and what does it cost?
• Do psychiatrists practice defensive medicine?
• Does defensive psychiatric practice lead to suboptimal care?
• Are some defensive practices justified?
• Can you balance good defense with good care?

What is defensive medicine?

In a 1994 study, the U.S. Office of Technology Assessment (OTA) said that defensive medicine occurs “when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily or solely) to reduce their exposure to malpractice liability.” This definition does not require that defensive clinical practices provide no benefit to patients, only that the expected benefits are small relative to their costs.⁸

Preventing the worst outcome

Studies suggest that doctors develop and maintain practice habits—consciously or not—that aim to reduce their risk of getting sued for malpractice. For example, when patients presenting with tick bites express concern about Lyme disease, doctors overuse tests and needlessly prescribe antibiotics.⁹ Although these practices are not evidence-based, they reduce doctors’ anxiety by “preventing the worst outcome at relatively little risk and cost and avoiding a potential lawsuit at the same time.”¹⁰

The OTA estimated that up to 8% of diagnostic procedures were ordered primarily because of conscious concern about malpractice liability, based on physicians’ responses to a set of written scenarios.⁸ In a recent study, 83% of Massachusetts physicians reported practicing defensive medicine and estimated that defensive reasons accounted for why they ordered:

• 18% of lab tests
• up to 30% of procedures and consultations
• 13% of hospitalizations.¹¹

Almost all high-liability specialists (such as emergency room physicians, surgeons, and obstetrician/gynecologists) report practicing defensive medicine, often gaging in “assurance behavior”—ordering tests, doing diagnostic procedures, and referring patients to consultants.¹²

Defensive psychiatry

Compared with other specialists, psychiatrists are at lower risk for being sued, but we engage in defensive practices nonetheless. A survey of British psychiatrists found that during the previous month, 75% made clinical decisions—such as “overcautiously” admitting patients or ordering special observation—because of worries about possible legal claims, complaints, or disciplinary action.¹³

Younger psychiatrists and psychiatrists who have experienced complaints and critical incidents are more likely to practice defensive medicine. This is hardly surprising—a malpractice suit can be very stressful.¹⁴ But an amorphous dread of lawsuits affects many psychiatrists, including residents who never have been sued. The result: many needless, countertherapeutic, defensive practices.^15,16

Unintended consequences

Defensive medicine is not just expensive and wasteful. It could increase your risk of litigation if practices result in harm.¹⁷ Simon and Shuman¹⁶ give examples of how attempts to avoid litigation can compromise clinical care when treating patients at risk for suicide:

• not prescribing clozapine—a treatment known to lower the risk of suicide¹⁸ —to a chronically suicidal patient with schizophrenia because of fears of agranulocytosis (see “Clozapine for schizophrenia: Life-threatening or life-saving treatment?” Current Psychiatry, December 2009)
• not recommending electroconvulsive therapy—and possibly prolonging the period when a severely depressed patient is at high risk for suicide—to avoid a lawsuit related to memory loss
• hospitalizing a patient at chronic risk for suicide who could be managed as an outpatient with appropriate safeguards, a practice that could undermine a valuable treatment alliance.

 

Good clinical care lowers the likelihood of harm to patients, making it a sound risk management practice, though not a complete strategy. Even the best doctors can start to think defensively when confronted with awkward, troubling, or life-threatening situations that could have medicolegal implications.¹⁶ For example, when an outpatient threatens to hurt someone else, it may be tempting to just confine him in a hospital (which reduces the doctor’s anxiety) even when other less coercive and more therapeutic options might better resolve the patient’s problems and the risk of violence.

Recognizing that you’re making clinical decisions out of fear of getting sued is the first step toward curtailing needlessly defensive practice. See Table ¹⁹ for more strategies.

Table

3 strategies for avoiding needless defensive medicine

Ask yourself, “If I weren’t worried about getting sued, what would I do?” or “If I were my patient, what would I want me to do?” These questions, which help you identify the best clinical response, also may help you to implement it without taking extraneous defensive measures.
“Never worry alone.” This recommendation from the Massachusetts General Hospital and McLean Hospital training programs19 means that if you’re concerned about a case, ask a colleague for a consultation. In addition to being helpful and reassuring, an outside perspective can support nondefensive, patient-oriented decision making.
If the treatment course you think is best involves a legal matter, make sure you understand the legal issues. For example, civil commitment is often the right intervention for a mentally ill person who poses a serious risk of harm, but some patients threaten to sue doctors who propose involuntary hospitalization. Your hospital’s attorney may provide explanation and legal guidance if you do not thoroughly understand legal mechanisms or whether you are properly invoking them

Justifiable defensiveness

Of course, it’s perfectly appropriate for psychiatrists to recognize malpractice risks and take appropriate measures to avoid successful lawsuits. For example, thoughtful documentation of your data gathering, decision making, and informed consent is an appropriate protective practice. Usually, no one sees the documentation, and it contributes little to your patients’ well-being. Good documentation can be inexpensive, however, and if done creatively, can improve data recording that in turn contributes to better treatment.²⁰

It happens every now and then: A physician is providing care to a patient and things aren’t going as smoothly as they should. In fact, the situation is deteriorating. The reasons vary, but the end result is almost always the same, and necessary—the physician-patient relationship must be terminated. When, why, and how the relationship ends can make the difference between an amicable separation and years of litigation. Terminating a relationship with a patient, however, presents special challenges for a hospitalist.

Relationship to Nowhere

Certainly, some days are better than others in all relationships, and physician-patient relationships are no exception.

Hospitalists regularly talk to patients about unpleasant realities. Each patient responds to the information differently. More often than not, these difficult conversations lead to a focused plan for dealing with a patient’s health needs. Sometimes, however, a patient refuses to acknowledge the information provided, responds in an abusive manner to the physician or hospital staff, or is simply noncompliant.

An isolated incident is one thing; an ongoing pattern is another. One key consideration is deterioration of trust—for example, when a physician suspects a patient is malingering or seeking drugs, or the patient lacks confidence in the physician.

Another example is when the hospitalist determines that hospitalization is no longer necessary but the patient or their family does not want the patient discharged. In such cases, a hospitalist cannot continue to order care that is not medically necessary. Nonetheless, if the patient experiences a future adverse outcome, the fact that the patient opposed discharge increases the potential for a lawsuit.

This is particularly true when a patient must be forcibly removed from the hospital. In such cases, it is always best to get another hospitalist and the patient’s primary-care physician involved. Having two or three concurring opinions from outside physicians can help temper the liability risk.

Perhaps most difficult is assessing the impact of external factors on a physician’s ability to provide care. A hospitalist might have a difficult time providing objective care to a patient who is covered by the insurance carrier that is investigating him, the friend of a patient who is suing him, or a close friend or family member. Most state medical boards provide physicians with guidance on “boundary issues,” which boil down to a simple principle: If personal feelings have the appearance of interfering with objective assessment or treatment of the patient, the patient’s care is better left to another hospitalist.

Transitioning Care and Abandonment

Deciding that a physician-patient relationship is no longer productive is only the beginning of a termination. Prohibitions on patient “abandonment” restrict a physician’s ability to immediately terminate a relationship. Particularly when a patient objects to discharge, it is extremely important to have a comprehensive post-discharge plan. Such a plan must include ensuring that outpatient care providers are available and willing to see the patient.

Even transitioning care to another provider must be handled carefully. As a hospitalist, you first must ensure that another provider is able to promptly take responsibility. It is not enough to just call the service to assign a new hospitalist. Rather, your responsibilities end only when the new provider sees the patient. Moreover, there should be a “handoff” so you can pinpoint when your obligations to the patient officially end.

Discrimination

Physicians may not refuse to treat a patient for a discriminatory reason. For example, federal and state laws prohibit discrimination based on race, religion, sex, national origin, disability, or age. Additionally, some states prohibit discrimination based on sexual orientation. So while a physician can decide not to treat lawyers (not a protected class), they are not allowed to refuse to treat someone because they are Hispanic, Muslim, or homosexual.

 

Conclusion

The simple answer to the question of when to terminate a physician-patient relationship is: whenever a conflict arises that is likely to impact the provision of care. Terminating the relationship in a manner that protects both the patient and the physician is the key to reducing potential liability. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

Image Source: CIMMERIAN/ISTOCKPHOTO.COM

It happens every now and then: A physician is providing care to a patient and things aren’t going as smoothly as they should. In fact, the situation is deteriorating. The reasons vary, but the end result is almost always the same, and necessary—the physician-patient relationship must be terminated. When, why, and how the relationship ends can make the difference between an amicable separation and years of litigation. Terminating a relationship with a patient, however, presents special challenges for a hospitalist.

Relationship to Nowhere

Certainly, some days are better than others in all relationships, and physician-patient relationships are no exception.

Hospitalists regularly talk to patients about unpleasant realities. Each patient responds to the information differently. More often than not, these difficult conversations lead to a focused plan for dealing with a patient’s health needs. Sometimes, however, a patient refuses to acknowledge the information provided, responds in an abusive manner to the physician or hospital staff, or is simply noncompliant.

An isolated incident is one thing; an ongoing pattern is another. One key consideration is deterioration of trust—for example, when a physician suspects a patient is malingering or seeking drugs, or the patient lacks confidence in the physician.

Another example is when the hospitalist determines that hospitalization is no longer necessary but the patient or their family does not want the patient discharged. In such cases, a hospitalist cannot continue to order care that is not medically necessary. Nonetheless, if the patient experiences a future adverse outcome, the fact that the patient opposed discharge increases the potential for a lawsuit.

This is particularly true when a patient must be forcibly removed from the hospital. In such cases, it is always best to get another hospitalist and the patient’s primary-care physician involved. Having two or three concurring opinions from outside physicians can help temper the liability risk.

Perhaps most difficult is assessing the impact of external factors on a physician’s ability to provide care. A hospitalist might have a difficult time providing objective care to a patient who is covered by the insurance carrier that is investigating him, the friend of a patient who is suing him, or a close friend or family member. Most state medical boards provide physicians with guidance on “boundary issues,” which boil down to a simple principle: If personal feelings have the appearance of interfering with objective assessment or treatment of the patient, the patient’s care is better left to another hospitalist.

Transitioning Care and Abandonment

Deciding that a physician-patient relationship is no longer productive is only the beginning of a termination. Prohibitions on patient “abandonment” restrict a physician’s ability to immediately terminate a relationship. Particularly when a patient objects to discharge, it is extremely important to have a comprehensive post-discharge plan. Such a plan must include ensuring that outpatient care providers are available and willing to see the patient.

Even transitioning care to another provider must be handled carefully. As a hospitalist, you first must ensure that another provider is able to promptly take responsibility. It is not enough to just call the service to assign a new hospitalist. Rather, your responsibilities end only when the new provider sees the patient. Moreover, there should be a “handoff” so you can pinpoint when your obligations to the patient officially end.

Discrimination

Physicians may not refuse to treat a patient for a discriminatory reason. For example, federal and state laws prohibit discrimination based on race, religion, sex, national origin, disability, or age. Additionally, some states prohibit discrimination based on sexual orientation. So while a physician can decide not to treat lawyers (not a protected class), they are not allowed to refuse to treat someone because they are Hispanic, Muslim, or homosexual.

 

Conclusion

The simple answer to the question of when to terminate a physician-patient relationship is: whenever a conflict arises that is likely to impact the provision of care. Terminating the relationship in a manner that protects both the patient and the physician is the key to reducing potential liability. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

Image Source: CIMMERIAN/ISTOCKPHOTO.COM

It happens every now and then: A physician is providing care to a patient and things aren’t going as smoothly as they should. In fact, the situation is deteriorating. The reasons vary, but the end result is almost always the same, and necessary—the physician-patient relationship must be terminated. When, why, and how the relationship ends can make the difference between an amicable separation and years of litigation. Terminating a relationship with a patient, however, presents special challenges for a hospitalist.

Relationship to Nowhere

Certainly, some days are better than others in all relationships, and physician-patient relationships are no exception.

Hospitalists regularly talk to patients about unpleasant realities. Each patient responds to the information differently. More often than not, these difficult conversations lead to a focused plan for dealing with a patient’s health needs. Sometimes, however, a patient refuses to acknowledge the information provided, responds in an abusive manner to the physician or hospital staff, or is simply noncompliant.

An isolated incident is one thing; an ongoing pattern is another. One key consideration is deterioration of trust—for example, when a physician suspects a patient is malingering or seeking drugs, or the patient lacks confidence in the physician.

Another example is when the hospitalist determines that hospitalization is no longer necessary but the patient or their family does not want the patient discharged. In such cases, a hospitalist cannot continue to order care that is not medically necessary. Nonetheless, if the patient experiences a future adverse outcome, the fact that the patient opposed discharge increases the potential for a lawsuit.

This is particularly true when a patient must be forcibly removed from the hospital. In such cases, it is always best to get another hospitalist and the patient’s primary-care physician involved. Having two or three concurring opinions from outside physicians can help temper the liability risk.

Perhaps most difficult is assessing the impact of external factors on a physician’s ability to provide care. A hospitalist might have a difficult time providing objective care to a patient who is covered by the insurance carrier that is investigating him, the friend of a patient who is suing him, or a close friend or family member. Most state medical boards provide physicians with guidance on “boundary issues,” which boil down to a simple principle: If personal feelings have the appearance of interfering with objective assessment or treatment of the patient, the patient’s care is better left to another hospitalist.

Transitioning Care and Abandonment

Deciding that a physician-patient relationship is no longer productive is only the beginning of a termination. Prohibitions on patient “abandonment” restrict a physician’s ability to immediately terminate a relationship. Particularly when a patient objects to discharge, it is extremely important to have a comprehensive post-discharge plan. Such a plan must include ensuring that outpatient care providers are available and willing to see the patient.

Even transitioning care to another provider must be handled carefully. As a hospitalist, you first must ensure that another provider is able to promptly take responsibility. It is not enough to just call the service to assign a new hospitalist. Rather, your responsibilities end only when the new provider sees the patient. Moreover, there should be a “handoff” so you can pinpoint when your obligations to the patient officially end.

Discrimination

Physicians may not refuse to treat a patient for a discriminatory reason. For example, federal and state laws prohibit discrimination based on race, religion, sex, national origin, disability, or age. Additionally, some states prohibit discrimination based on sexual orientation. So while a physician can decide not to treat lawyers (not a protected class), they are not allowed to refuse to treat someone because they are Hispanic, Muslim, or homosexual.

 

Conclusion

The simple answer to the question of when to terminate a physician-patient relationship is: whenever a conflict arises that is likely to impact the provision of care. Terminating the relationship in a manner that protects both the patient and the physician is the key to reducing potential liability. TH

Patrick O’Rourke works in the Office of University Counsel, Department of Litigation, University of Colorado, Denver.

Image Source: CIMMERIAN/ISTOCKPHOTO.COM

While spending a summer taking care of her mother-in-law, who was ill with colon cancer, Lynne Allen, MN, ARNP, heard her calling loud and clear. “I thought, ‘Wow, I can do this,’ ” she says. “A lot of people can’t do this.”

Allen had completed a year of nursing school right after high school but never finished. So she decided to go back to school and earn a nursing degree. She graduated from the University of Washington’s Adult Acute Care Nurse Practitioner Program in 2001 and later landed a job at Columbia Basin Hematology and Oncology, a private practice in Kennewick, Wash.

At the time, a then-burgeoning hospitalist group based in Brentwood, Tenn., was looking to recruit nurses. Cogent Healthcare made Allen an offer. The idea of working in a hospital where doctors would be available 24 hours a day, seven days a week, intrigued Allen. “I was a house supervisor in grad school and always remember thinking, ‘If only I had a physician in here, I could take care of this problem in two minutes,’ ” she says.

Allen accepted the offer and went to work in Cogent’s nonphysician clinical development program. Last year, she returned to Columbia Basin, where she makes hospitalist rounds four times a week at Kadlec Regional Medical Center in Richland, Wash. Allen, the newest member of Team Hospitalist, recently spoke with The Hospitalist about the unique perspective nurse practitioners (NPs) offer HM.

Question: What do you like about working with hospitalists?

Answer: I like the teamwork involved. I really like going in the morning and seeing that the nurses cared for the patients all night and know what is going on. I like knowing that they can feel comfortable calling me about what they need and making a difference. In terms of hospital medicine, just because [a patient] stays a long time doesn’t mean they are getting the quality of care they need. There are other issues involved with that, especially in cancer patients. They are afraid to go home, afraid of dying. If you have a patient with cancer or COPD [chronic obstructive pulmonary disease] and they are probably not going to live as long as they would normally, you begin to talk to them about their goals for themselves, in terms of quality of life.

Q: How do you initiate that conversation?

A: Medicare has made it very easy, because every patient that comes in should be asked if they have a living will, so you bring that subject up. Most people, when they are dying, they know it. The rest of the family is surprised, but the patient knows it. Sometimes you just bring it up point-blank.

PHOTOS COURTESY OF LYNNE ALLEN

Q: Why does HM present an opportunity for NPs?

A: I think workforce is one of the issues. I think there are a lot of nurses out there who have worked in a hospital and love that acute-care environment. It is very different than working in a clinic. I do both right now, and there is such a difference in what you need to know about your patients and how you treat them.

 

Q: How is it different?

A: When you are in an outpatient center, [patients] are there and you are probably giving them meds if they are getting chemotherapy and need some support. In an inpatient setting, they are there all the time. It’s a 24/7 need for support. I see this as another special area NPs can take. It’s in the stage of infancy, and it will grow.

Q: Do you think your background in nursing has helped you interact better with patients?

A: Yes. It is part of “who” nurses are. I really enjoy being able to take care of the patients that need the open communication, because it does help them.

Q: What unique perspective do NPs bring to HM?

A: I think nurses are taught to look at the whole patient. We are not taught to specifically say, “This patient has these symptoms, this disease process, this treatment.” … They have family. They have social issues. They have spiritual issues. [It all plays] into their disease process and their treatment process.

Q: What’s the one thing about NPs that most hospitalists don’t get?

A: We are trained to practice independently. In my state, Washington, I can be a completely independent practitioner. We are also taught to know when to consult or collaborate with a physician. I think sometimes physicians don’t recognize that or understand that. They think that we just want to be more independent. HM is a team effort, and we are willing to be part of the team with an equal partnership.

Q: What are some of the issues that come up between NPs and hospitalists?

A: Physicians are not trained to delegate. They are trained that you are in control, you are the one in charge of this patient’s care, you will dictate what goes on with this patient. Medicare and Medicaid require an attending physician, so for a physician to put [his or her] name on there and trust someone else to assess and develop a care plan is hard for them. And I can’t blame them.

Give it a chance, work together, and develop that relationship. Don’t expect it to be there right at day one. And it might not even be six months, but you need to be open-minded and willing to work with someone who is willing to work with you, and not just think it is about giving orders.

Q: What qualities should hospitalists look for in hiring NPs?

A: They should look for someone who has actually worked in a hospital, who is interested in working on a team, who is interested in developing their own capacity or intellectual ability to take care of patients—and recognize that there is going to be a learning curve there. They should also look for someone who is pleasant and who seems to fit in with the team. TH

Stephanie Cajigal is associate editor of The Hospitalist.

While spending a summer taking care of her mother-in-law, who was ill with colon cancer, Lynne Allen, MN, ARNP, heard her calling loud and clear. “I thought, ‘Wow, I can do this,’ ” she says. “A lot of people can’t do this.”

Allen had completed a year of nursing school right after high school but never finished. So she decided to go back to school and earn a nursing degree. She graduated from the University of Washington’s Adult Acute Care Nurse Practitioner Program in 2001 and later landed a job at Columbia Basin Hematology and Oncology, a private practice in Kennewick, Wash.

At the time, a then-burgeoning hospitalist group based in Brentwood, Tenn., was looking to recruit nurses. Cogent Healthcare made Allen an offer. The idea of working in a hospital where doctors would be available 24 hours a day, seven days a week, intrigued Allen. “I was a house supervisor in grad school and always remember thinking, ‘If only I had a physician in here, I could take care of this problem in two minutes,’ ” she says.

Allen accepted the offer and went to work in Cogent’s nonphysician clinical development program. Last year, she returned to Columbia Basin, where she makes hospitalist rounds four times a week at Kadlec Regional Medical Center in Richland, Wash. Allen, the newest member of Team Hospitalist, recently spoke with The Hospitalist about the unique perspective nurse practitioners (NPs) offer HM.

Question: What do you like about working with hospitalists?

Answer: I like the teamwork involved. I really like going in the morning and seeing that the nurses cared for the patients all night and know what is going on. I like knowing that they can feel comfortable calling me about what they need and making a difference. In terms of hospital medicine, just because [a patient] stays a long time doesn’t mean they are getting the quality of care they need. There are other issues involved with that, especially in cancer patients. They are afraid to go home, afraid of dying. If you have a patient with cancer or COPD [chronic obstructive pulmonary disease] and they are probably not going to live as long as they would normally, you begin to talk to them about their goals for themselves, in terms of quality of life.

Q: How do you initiate that conversation?

A: Medicare has made it very easy, because every patient that comes in should be asked if they have a living will, so you bring that subject up. Most people, when they are dying, they know it. The rest of the family is surprised, but the patient knows it. Sometimes you just bring it up point-blank.

PHOTOS COURTESY OF LYNNE ALLEN

Q: Why does HM present an opportunity for NPs?

A: I think workforce is one of the issues. I think there are a lot of nurses out there who have worked in a hospital and love that acute-care environment. It is very different than working in a clinic. I do both right now, and there is such a difference in what you need to know about your patients and how you treat them.

 

Q: How is it different?

A: When you are in an outpatient center, [patients] are there and you are probably giving them meds if they are getting chemotherapy and need some support. In an inpatient setting, they are there all the time. It’s a 24/7 need for support. I see this as another special area NPs can take. It’s in the stage of infancy, and it will grow.

Q: Do you think your background in nursing has helped you interact better with patients?

A: Yes. It is part of “who” nurses are. I really enjoy being able to take care of the patients that need the open communication, because it does help them.

Q: What unique perspective do NPs bring to HM?

A: I think nurses are taught to look at the whole patient. We are not taught to specifically say, “This patient has these symptoms, this disease process, this treatment.” … They have family. They have social issues. They have spiritual issues. [It all plays] into their disease process and their treatment process.

Q: What’s the one thing about NPs that most hospitalists don’t get?

A: We are trained to practice independently. In my state, Washington, I can be a completely independent practitioner. We are also taught to know when to consult or collaborate with a physician. I think sometimes physicians don’t recognize that or understand that. They think that we just want to be more independent. HM is a team effort, and we are willing to be part of the team with an equal partnership.

Q: What are some of the issues that come up between NPs and hospitalists?

A: Physicians are not trained to delegate. They are trained that you are in control, you are the one in charge of this patient’s care, you will dictate what goes on with this patient. Medicare and Medicaid require an attending physician, so for a physician to put [his or her] name on there and trust someone else to assess and develop a care plan is hard for them. And I can’t blame them.

Give it a chance, work together, and develop that relationship. Don’t expect it to be there right at day one. And it might not even be six months, but you need to be open-minded and willing to work with someone who is willing to work with you, and not just think it is about giving orders.

Q: What qualities should hospitalists look for in hiring NPs?

A: They should look for someone who has actually worked in a hospital, who is interested in working on a team, who is interested in developing their own capacity or intellectual ability to take care of patients—and recognize that there is going to be a learning curve there. They should also look for someone who is pleasant and who seems to fit in with the team. TH

Stephanie Cajigal is associate editor of The Hospitalist.

While spending a summer taking care of her mother-in-law, who was ill with colon cancer, Lynne Allen, MN, ARNP, heard her calling loud and clear. “I thought, ‘Wow, I can do this,’ ” she says. “A lot of people can’t do this.”

Allen had completed a year of nursing school right after high school but never finished. So she decided to go back to school and earn a nursing degree. She graduated from the University of Washington’s Adult Acute Care Nurse Practitioner Program in 2001 and later landed a job at Columbia Basin Hematology and Oncology, a private practice in Kennewick, Wash.

At the time, a then-burgeoning hospitalist group based in Brentwood, Tenn., was looking to recruit nurses. Cogent Healthcare made Allen an offer. The idea of working in a hospital where doctors would be available 24 hours a day, seven days a week, intrigued Allen. “I was a house supervisor in grad school and always remember thinking, ‘If only I had a physician in here, I could take care of this problem in two minutes,’ ” she says.

Allen accepted the offer and went to work in Cogent’s nonphysician clinical development program. Last year, she returned to Columbia Basin, where she makes hospitalist rounds four times a week at Kadlec Regional Medical Center in Richland, Wash. Allen, the newest member of Team Hospitalist, recently spoke with The Hospitalist about the unique perspective nurse practitioners (NPs) offer HM.

Question: What do you like about working with hospitalists?

Answer: I like the teamwork involved. I really like going in the morning and seeing that the nurses cared for the patients all night and know what is going on. I like knowing that they can feel comfortable calling me about what they need and making a difference. In terms of hospital medicine, just because [a patient] stays a long time doesn’t mean they are getting the quality of care they need. There are other issues involved with that, especially in cancer patients. They are afraid to go home, afraid of dying. If you have a patient with cancer or COPD [chronic obstructive pulmonary disease] and they are probably not going to live as long as they would normally, you begin to talk to them about their goals for themselves, in terms of quality of life.

Q: How do you initiate that conversation?

A: Medicare has made it very easy, because every patient that comes in should be asked if they have a living will, so you bring that subject up. Most people, when they are dying, they know it. The rest of the family is surprised, but the patient knows it. Sometimes you just bring it up point-blank.

PHOTOS COURTESY OF LYNNE ALLEN

Q: Why does HM present an opportunity for NPs?

A: I think workforce is one of the issues. I think there are a lot of nurses out there who have worked in a hospital and love that acute-care environment. It is very different than working in a clinic. I do both right now, and there is such a difference in what you need to know about your patients and how you treat them.

 

Q: How is it different?

A: When you are in an outpatient center, [patients] are there and you are probably giving them meds if they are getting chemotherapy and need some support. In an inpatient setting, they are there all the time. It’s a 24/7 need for support. I see this as another special area NPs can take. It’s in the stage of infancy, and it will grow.

Q: Do you think your background in nursing has helped you interact better with patients?

A: Yes. It is part of “who” nurses are. I really enjoy being able to take care of the patients that need the open communication, because it does help them.

Q: What unique perspective do NPs bring to HM?

A: I think nurses are taught to look at the whole patient. We are not taught to specifically say, “This patient has these symptoms, this disease process, this treatment.” … They have family. They have social issues. They have spiritual issues. [It all plays] into their disease process and their treatment process.

Q: What’s the one thing about NPs that most hospitalists don’t get?

A: We are trained to practice independently. In my state, Washington, I can be a completely independent practitioner. We are also taught to know when to consult or collaborate with a physician. I think sometimes physicians don’t recognize that or understand that. They think that we just want to be more independent. HM is a team effort, and we are willing to be part of the team with an equal partnership.

Q: What are some of the issues that come up between NPs and hospitalists?

A: Physicians are not trained to delegate. They are trained that you are in control, you are the one in charge of this patient’s care, you will dictate what goes on with this patient. Medicare and Medicaid require an attending physician, so for a physician to put [his or her] name on there and trust someone else to assess and develop a care plan is hard for them. And I can’t blame them.

Give it a chance, work together, and develop that relationship. Don’t expect it to be there right at day one. And it might not even be six months, but you need to be open-minded and willing to work with someone who is willing to work with you, and not just think it is about giving orders.

Q: What qualities should hospitalists look for in hiring NPs?

A: They should look for someone who has actually worked in a hospital, who is interested in working on a team, who is interested in developing their own capacity or intellectual ability to take care of patients—and recognize that there is going to be a learning curve there. They should also look for someone who is pleasant and who seems to fit in with the team. TH

Stephanie Cajigal is associate editor of The Hospitalist.

One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.

Discharge Day Management

Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

 

Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.

Shared/Split Services

Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).

The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.

In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3

Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4

Teaching Physician Services

A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.

The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
4. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
5. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
6. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
8. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.

One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.

Discharge Day Management

Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

 

Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.

Shared/Split Services

Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).

The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.

In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3

Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4

Teaching Physician Services

A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.

The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
4. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
5. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
6. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
8. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.

One constant in all the modifications to billing and reimbursement guidelines for evaluation and management (E/M) services provided by hospitalists is that a face-to-face patient encounter by the billing provider is required. Exceptions do occur (e.g., telehealth services, care plan oversight, home health certification) but are infrequently reported by hospitalist teams. Do not get caught misreporting the following services due to the absence of a physician presence.

Discharge Day Management

Hospital discharge day management (CPT 99238-99239) is a face-to-face E/M service between the attending physician and the patient. Document the date of the actual physician visit even if the patient is discharged from the facility on a different date.1 Documentation must substantiate this personal patient encounter.

A hospitalist can choose to record the face-to-face encounter in a handwritten progress note or make note of it in the formal discharge summary. When relying solely upon the dictated summary, physicians often fail to identify personal contact with the patient. Although an examination need only be performed “as appropriate” on the day of discharge, it is the best indicator of a face-to-face encounter. Such statements as “Upon discharge, the patient appeared well, vital signs stable, lungs clear” or “Patient seen and examined by me on discharge day” clearly illustrate this service.

It is important to note that only the attending physician of record reports the discharge day management service. Physicians or qualified non-physician practitioners (NPPs), other than the attending physician, who have been managing concurrent healthcare problems not primarily managed by the attending physician and who are not acting on behalf of the attending physician should use subsequent hospital care codes (99231-99233) for a final visit.2

 

Death pronouncement can be reported with discharge day management codes (99238-99239), but only when this service involves a physician-patient encounter. Physicians should report the most appropriate discharge code on the actual day of pronouncement.

Shared/Split Services

Shared/split Medicare services occur when two providers from the same specialty and group practice perform a portion of a facility-based (outpatient hospital, inpatient hospital, or ED) patient encounter on the same day. One provider must be a physician; the other must be a qualified and certified NPP (e.g., nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwife).

The culmination of the two portions of service must fulfill the requirements of a single E/M service (consultations, critical care, and other time-based services excluded). The physician has the option to report the shared/split service to Medicare under their name for 100% of the allowable reimbursement rate, or under the NPP’s name for 85% of the allowable reimbursement rate.

In order to utilize this billing model, the physician and the NPP must provide a face-to-face encounter on the same day. If there is no face-to-face encounter between the patient and the physician, then the service can only be billed under the NPP’s name at 85% of the allowable reimbursement rate.3

Documentation must clearly identify each provider involved in the shared/split service, along with the presence and the portion of each individual’s service. The NPP and the physician should each indicate the extent of their involvement (e.g., “Patient seen and examined by me … ”) in the patient’s care and sign their portion of the note. If the NPP and physician each write a separate note, each note should refer to the other provider. That way, the supporting documentation for the service rendered encompasses the summation of both notes.4

Teaching Physician Services

A different type of shared service can occur under the teaching physician rules, whereby an attending physician and a “resident” are involved in the same patient encounter. The term “resident” also includes interns and fellows in recognized graduate medical education (GME) programs, as approved for purposes of direct GME payments made by the fiscal intermediary.5 As with services shared with NPPs, the attending physician must provide a face-to-face encounter and participate in a key portion of the service.

The attending physician can perform their portion of the service concurrently or independent of the resident but is allowed to discuss the case (teaching service) with the resident, as appropriate. If the attending physician does not physically see the patient, the service cannot be reported. Payment is made only for the teaching physician’s involvement in the patient’s care.

Instead of detailing the entire encounter, the teaching physician should write a short, legible linking or tethering statement specifically referencing the resident’s note. Physicians must demonstrate their physical presence (e.g., “Patient seen and examined by me. Agree with note by Dr. Jones”) and comment on the patient’s evaluation and their active involvement in the care plan.6 TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References

1. Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare and Medicaid Services (CMS) Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.2B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
3. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
4. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;265-271.
5. Medicare Claims Processing Manual: Chapter 12, Section 100. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
6. Manaker, S. Teaching Physician Regulations. In: Coding for Chest Medicine 2009. Northbrook, IL: American College of Chest Physicians, 2008;299-305.
7. Medicare Claims Processing Manual: Chapter 12, Section 30.6.9.1D. CMS Web site. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12. pdf. Accessed July 5, 2009.
8. Beebe M, Dalton J, Espronceda M, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2008.

The struggle over U.S. healthcare reform has consumed Congress for most of the year. It has dominated media coverage and fueled informal debates in all parts of the country. A resolution to the heated back-and-forth should arrive by Thanksgiving in the form of meaningful healthcare legislation, according to Vice President Joe Biden. Then again, Sen. Jim DeMint (R-S.C.) has pledged to cancel the Democrats’ planned festivities, preventing what he and other opponents have described as a “government takeover” of the healthcare system.

Amid the emotional tug-of-war and evolving bills, the nonpartisan Congressional Budget Office (CBO) has laid out the stakes. In a June letter to the Senate Budget Committee, CBO Director Douglas W. Elmendorf begins: “In the absence of significant changes in policy, rising costs for healthcare will cause federal spending to grow much faster than the economy, putting the federal budget on an unsustainable path.”

Most experts, analysts, and politicians agree that something must be done. It’s all a matter of what and how much it will cost. In the spirit of Thanksgiving, let’s talk turkey about the healthcare reform proposals that may or may not survive the holiday, and the key players who will determine whether this year’s reform effort stays alive—or gets stuffed.

Main Points of Disagreement

Whether healthcare reform should include a public option for a national insurance plan, smaller nonprofit co-ops, or nothing of the sort has dominated the debate over the competing proposals in Congress. But it’s hardly the only major disagreement.

Beyond the sticky matter of how to pay for everything, businesses instinctively have opposed any requirement that employers offer health insurance to their employees. Then again, that opposition seems to be softening as more details of the plan are released.

In principle, widespread agreement exists on the notion that individuals should have guaranteed issue and renewability of their healthcare insurance, regardless of pre-existing conditions. Far less clear, however, is the matter of how much those individuals will have to pay for their policies.

Main Points of Agreement

Not everyone is on board, but any healthcare reform bill that emerges from Congress is likely to contain three main elements, according to Leighton Ku, director of the Center for Health Policy Research at George Washington University in Washington, D.C.

1. Expansion of Medicaid

Details are still in flux, and some lawmakers have grumbled about the potential cost to states, but Ku says broad agreement exists for an expansion of Medicaid that would cover individuals and families who earn up to 133 percent or so of the federal poverty line. Estimates suggest that an additional 9 million uninsured, low-income adults could be covered. “That’s a huge swath right there that we can take out of the uninsured category,” he says.

2. Health Insurance Exchanges

Think of exchanges as the Travelocity or Orbitz for health-insurance plans, complete with coupons for the needy. Sliding-scale tax credits or vouchers could be used by low- to moderate-income people to buy insurance in publicly available, government-regulated marketplaces where such parameters as premiums and coverage could be compared. “The concept is that by setting up standards and having a place where it’s all together, it would create a competition,” Ku says.

In essence, more competition could lead to cost reductions.

3. An Individual Mandate

Hardship exemptions are likely, but people who can afford it will be expected to buy insurance or pay a penalty. Republican rumblings suggest that agreement on this point may not be as widespread as initially thought.

Main Players

President Obama has made healthcare reform the centerpiece of his first-year agenda. If he is to succeed, organizations like AARP will be key in winning over skeptical seniors. But the real power lies with a handful of Congressional leaders who have the ability to make or break any legislation. A brief rundown:

 

Senate

The illness and death of longtime healthcare reform advocate Sen. Edward Kennedy (D-Mass.) shifted the Congressional spotlight to Sen. Max Baucus (D-Mont.), right, chairman of the Senate Finance Committee and leader of the committee’s “Gang of Six” negotiators—three Democrats and three Republicans. In mid-September, Baucus unveiled his preliminary “mark” of the America’s Healthy Future Act. He did so without any Republican endorsement.

The overhaul is less expensive and more moderate than the America’s Affordable Health Choices Act, introduced in the House of Representatives, and a partial bill passed earlier by Sen. Kennedy’s Health, Education, Labor and Pensions (HELP) Committee. Nevertheless, progressives and conservatives criticized the Baucus plan. Even so, Sen. Olympia Snowe (R-Maine) has become a major focus of Democrats’ efforts to find 60 votes and avoid a Republican filibuster, though the seating of a replacement for Sen. Kennedy would help Democrats regain a filibuster-proof majority. One key point: Analysts say bringing Sen. Snowe on board might not win other Republican votes, but she might offer cover for such conservative Democratic senators as Mary Landrieu (D-La.) and Ben Nelson (D-Neb.).

As a last resort, Democrats have raised the possibility of using reconciliation, an arcane process originally intended for budgetary items. Reconciliation requires only a 51-vote majority, but complicated rules and a promised Republican challenge could lead to chaos.

House

Speaker Nancy Pelosi (D-Calif.), left, and Rep. Henry Waxman (D-Calif.) have dominated the stage, but they have had to balance the priorities of the chamber’s progressive wing with the concerns of the “Blue Dog” contingent of conservative Democrats.

Paying For It All

Meaningful reform without breaking the bank is a common refrain in healthcare discussions. Despite heated disputes over taxes, fees, fines, and service cuts to help defray costs, two main mechanisms for savings have emerged, according to the Center for Health Policy Research’s Ku:

1. Curbing Medicare Advantage

With the creation of Medicare drug benefits in 2003, Medicare’s managed-care plans run by private companies were revamped and renamed Medicare Advantage Plans. In return for extra benefits or lower co-payments, the 22% of Medicare beneficiaries enrolled in these plans are generally limited to in-network doctors or hospitals. Based on Medicare Payment Advisory Commission estimates, Medicare reimburses the private plans, on average, 14% more than standard Medicare fee-for-service plans—or an additional $12 billion in 2009.

One cost-cutting idea would be to restore a level playing field, Ku says, and pay managed care on par with Medicare and Medicaid. “This is one of the largest components of savings that people are anticipating,” he adds. A backlash by seniors, however, has led to a “grandfathering” clause that would protect the extra benefits in certain parts of the country, potentially reducing the overall savings.

2. Disproportionate Share Hospital (DSH) Cuts

Both Medicare and Medicaid pay extra to hospitals that serve a high proportion of needy patients. The savings mechanism here is less clear, but the expectation is that because the number of uninsured patients will drop dramatically with legislation, the DSH payments could be scaled back as well. The cuts, phased in over a decade, could amount to tens of billions of dollars in overall savings, though the House and Senate Finance bills differ in how deep the trims should be.

For More Information

• Kaiser Family Foundation
  

  http://healthreform.kff.org

  
  

  The foundation’s comprehensive “Health Reform” page offers a side-by-side comparison of 12 healthcare proposals, including both Democratic and Republican bills.

• Congressional Budget Office
  

  www.cbo.gov
  

  The nonpartisan office has already weighed in on the economic effects of preliminary versions of the competing healthcare reform bills, and will likely do so again.

• FactCheck.org
  

  A project of The University of Pennsylvania’s Annenberg Public Policy Center, the site has debunked dozens of healthcare reform myths.

• PolitiFact.com
  

  The Truth-O-Meter, a project of the St. Petersburg Times, has put recent healthcare assertions into categories ranging from “True” (substantiated assertions) to “Pants on Fire” (for absurd untruths).

• HospitalMedicine.org/advocacy
  

  SHM updates health reform progress and offers a monthly “Washington Update” outlining the society’s policy positions and activities.

 

Other Proposals to Keep an Eye On

• Addition of a hospital value-based purchasing (VBP) program to Medicare, which would tie incentive payments to performance on various quality measures;
• Expansion of the Physician’s Quality Reporting Initiative (PQRI), with a 1% payment penalty by 2012 for nonparticipants;
• Creation of a CMS payment innovation center to try out new payment structures, with the goal of improving quality and reducing Medicare costs; and
• Establishment of a Medicare pilot initiative called the Community Care Transitions Program, which would spend $500 million over 10 years on efforts to reduce preventable rehospitalizations; SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify.

Four Proposals Hospitalists Should Know About

1. Fixes to Medicare’s Physician Fee Schedule

The House bill would provide $228.5 billion to repeal the sustainable growth rate (SGR) used to determine the annual physician fee schedule and eliminate accumulated SGR debt, preventing a potential 21.5% cut in 2010 reimbursement fees. The more cost-conscious Senate Finance bill, by contrast, provides a one-year patch, providing a 0.5% update instead of any cut, but it leaves the SGR in place. “We understand the budgetary constraints that Senator Baucus is working with, but we’re disappointed that the SGR is getting another patch,” says Eric Siegal, MD, FHM, chair of SHM’s Public Policy Committee. “If we’re going to talk about restructuring healthcare, then we also need a payment system that is stable and that is not subject to the yearly whims of Congress.”

2. Medical Liability Reform

The Senate Finance plan’s nonbinding “Sense of the Senate,” which encourages states to pursue alternatives to the current civil litigation system, is a “missed opportunity,” according to Dr. Siegal. “We think that the Senate Finance Committee should have gone further with this,” he says, noting that medical liability is a significant driver of unnecessary healthcare expenses. The House bill is more robust in pushing medical malpractice reform by offering states federal assistance, Dr. Siegal says, but still leaves room for improvement.

3. Primary-Care Bonus Payments

Conceptually, the Senate and the House bills offer similar proposals to improve reimbursements for primary care, something Dr. Siegal says SHM has consistently and strongly supported “as a way of preventing further erosion of the primary-care infrastructure.” Depending on how the Senate Finance plan defines “primary care,” hospitalists might benefit directly. “Even if you get past the issue of whether it hits our pocketbook favorably,” Dr. Siegal says, “it is in the strategic interest of our specialty to have a strong primary-care base.”

4. Bundled Payments

Proposals in both the Senate and House bills for a pilot program aimed at bundling payments around an episode of care have been greeted cautiously by hospitalists, as have other new payment proposals. Robust and meaningful demonstration projects, Dr. Siegal says, are necessary to get a better sense of what the consequences could be, intended or otherwise. “Any time you’re talking about changes to the fundamental architecture of how we pay people for what they do, you’d better spend some time looking into what the implications of that are,” he says. TH

Bryn Nelson is a freelance writer based in Seattle.

Image Sources: KASH76, DIADEMIMAGES, DAVID GUNN, TOMENG, ALEXEY KASHIN, JONATHAN LARSEN, JON HELGASON, STEFAN KLEIN, SX70, SDOMINICK/ISTOCKPHOTO.COM

The struggle over U.S. healthcare reform has consumed Congress for most of the year. It has dominated media coverage and fueled informal debates in all parts of the country. A resolution to the heated back-and-forth should arrive by Thanksgiving in the form of meaningful healthcare legislation, according to Vice President Joe Biden. Then again, Sen. Jim DeMint (R-S.C.) has pledged to cancel the Democrats’ planned festivities, preventing what he and other opponents have described as a “government takeover” of the healthcare system.

Amid the emotional tug-of-war and evolving bills, the nonpartisan Congressional Budget Office (CBO) has laid out the stakes. In a June letter to the Senate Budget Committee, CBO Director Douglas W. Elmendorf begins: “In the absence of significant changes in policy, rising costs for healthcare will cause federal spending to grow much faster than the economy, putting the federal budget on an unsustainable path.”

Most experts, analysts, and politicians agree that something must be done. It’s all a matter of what and how much it will cost. In the spirit of Thanksgiving, let’s talk turkey about the healthcare reform proposals that may or may not survive the holiday, and the key players who will determine whether this year’s reform effort stays alive—or gets stuffed.

Main Points of Disagreement

Whether healthcare reform should include a public option for a national insurance plan, smaller nonprofit co-ops, or nothing of the sort has dominated the debate over the competing proposals in Congress. But it’s hardly the only major disagreement.

Beyond the sticky matter of how to pay for everything, businesses instinctively have opposed any requirement that employers offer health insurance to their employees. Then again, that opposition seems to be softening as more details of the plan are released.

In principle, widespread agreement exists on the notion that individuals should have guaranteed issue and renewability of their healthcare insurance, regardless of pre-existing conditions. Far less clear, however, is the matter of how much those individuals will have to pay for their policies.

Main Points of Agreement

Not everyone is on board, but any healthcare reform bill that emerges from Congress is likely to contain three main elements, according to Leighton Ku, director of the Center for Health Policy Research at George Washington University in Washington, D.C.

1. Expansion of Medicaid

Details are still in flux, and some lawmakers have grumbled about the potential cost to states, but Ku says broad agreement exists for an expansion of Medicaid that would cover individuals and families who earn up to 133 percent or so of the federal poverty line. Estimates suggest that an additional 9 million uninsured, low-income adults could be covered. “That’s a huge swath right there that we can take out of the uninsured category,” he says.

2. Health Insurance Exchanges

Think of exchanges as the Travelocity or Orbitz for health-insurance plans, complete with coupons for the needy. Sliding-scale tax credits or vouchers could be used by low- to moderate-income people to buy insurance in publicly available, government-regulated marketplaces where such parameters as premiums and coverage could be compared. “The concept is that by setting up standards and having a place where it’s all together, it would create a competition,” Ku says.

In essence, more competition could lead to cost reductions.

3. An Individual Mandate

Hardship exemptions are likely, but people who can afford it will be expected to buy insurance or pay a penalty. Republican rumblings suggest that agreement on this point may not be as widespread as initially thought.

Main Players

President Obama has made healthcare reform the centerpiece of his first-year agenda. If he is to succeed, organizations like AARP will be key in winning over skeptical seniors. But the real power lies with a handful of Congressional leaders who have the ability to make or break any legislation. A brief rundown:

 

Senate

The illness and death of longtime healthcare reform advocate Sen. Edward Kennedy (D-Mass.) shifted the Congressional spotlight to Sen. Max Baucus (D-Mont.), right, chairman of the Senate Finance Committee and leader of the committee’s “Gang of Six” negotiators—three Democrats and three Republicans. In mid-September, Baucus unveiled his preliminary “mark” of the America’s Healthy Future Act. He did so without any Republican endorsement.

The overhaul is less expensive and more moderate than the America’s Affordable Health Choices Act, introduced in the House of Representatives, and a partial bill passed earlier by Sen. Kennedy’s Health, Education, Labor and Pensions (HELP) Committee. Nevertheless, progressives and conservatives criticized the Baucus plan. Even so, Sen. Olympia Snowe (R-Maine) has become a major focus of Democrats’ efforts to find 60 votes and avoid a Republican filibuster, though the seating of a replacement for Sen. Kennedy would help Democrats regain a filibuster-proof majority. One key point: Analysts say bringing Sen. Snowe on board might not win other Republican votes, but she might offer cover for such conservative Democratic senators as Mary Landrieu (D-La.) and Ben Nelson (D-Neb.).

As a last resort, Democrats have raised the possibility of using reconciliation, an arcane process originally intended for budgetary items. Reconciliation requires only a 51-vote majority, but complicated rules and a promised Republican challenge could lead to chaos.

House

Speaker Nancy Pelosi (D-Calif.), left, and Rep. Henry Waxman (D-Calif.) have dominated the stage, but they have had to balance the priorities of the chamber’s progressive wing with the concerns of the “Blue Dog” contingent of conservative Democrats.

Paying For It All

Meaningful reform without breaking the bank is a common refrain in healthcare discussions. Despite heated disputes over taxes, fees, fines, and service cuts to help defray costs, two main mechanisms for savings have emerged, according to the Center for Health Policy Research’s Ku:

1. Curbing Medicare Advantage

With the creation of Medicare drug benefits in 2003, Medicare’s managed-care plans run by private companies were revamped and renamed Medicare Advantage Plans. In return for extra benefits or lower co-payments, the 22% of Medicare beneficiaries enrolled in these plans are generally limited to in-network doctors or hospitals. Based on Medicare Payment Advisory Commission estimates, Medicare reimburses the private plans, on average, 14% more than standard Medicare fee-for-service plans—or an additional $12 billion in 2009.

One cost-cutting idea would be to restore a level playing field, Ku says, and pay managed care on par with Medicare and Medicaid. “This is one of the largest components of savings that people are anticipating,” he adds. A backlash by seniors, however, has led to a “grandfathering” clause that would protect the extra benefits in certain parts of the country, potentially reducing the overall savings.

2. Disproportionate Share Hospital (DSH) Cuts

Both Medicare and Medicaid pay extra to hospitals that serve a high proportion of needy patients. The savings mechanism here is less clear, but the expectation is that because the number of uninsured patients will drop dramatically with legislation, the DSH payments could be scaled back as well. The cuts, phased in over a decade, could amount to tens of billions of dollars in overall savings, though the House and Senate Finance bills differ in how deep the trims should be.

For More Information

• Kaiser Family Foundation
  

  http://healthreform.kff.org

  
  

  The foundation’s comprehensive “Health Reform” page offers a side-by-side comparison of 12 healthcare proposals, including both Democratic and Republican bills.

• Congressional Budget Office
  

  www.cbo.gov
  

  The nonpartisan office has already weighed in on the economic effects of preliminary versions of the competing healthcare reform bills, and will likely do so again.

• FactCheck.org
  

  A project of The University of Pennsylvania’s Annenberg Public Policy Center, the site has debunked dozens of healthcare reform myths.

• PolitiFact.com
  

  The Truth-O-Meter, a project of the St. Petersburg Times, has put recent healthcare assertions into categories ranging from “True” (substantiated assertions) to “Pants on Fire” (for absurd untruths).

• HospitalMedicine.org/advocacy
  

  SHM updates health reform progress and offers a monthly “Washington Update” outlining the society’s policy positions and activities.

 

Other Proposals to Keep an Eye On

• Addition of a hospital value-based purchasing (VBP) program to Medicare, which would tie incentive payments to performance on various quality measures;
• Expansion of the Physician’s Quality Reporting Initiative (PQRI), with a 1% payment penalty by 2012 for nonparticipants;
• Creation of a CMS payment innovation center to try out new payment structures, with the goal of improving quality and reducing Medicare costs; and
• Establishment of a Medicare pilot initiative called the Community Care Transitions Program, which would spend $500 million over 10 years on efforts to reduce preventable rehospitalizations; SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify.

Four Proposals Hospitalists Should Know About

1. Fixes to Medicare’s Physician Fee Schedule

The House bill would provide $228.5 billion to repeal the sustainable growth rate (SGR) used to determine the annual physician fee schedule and eliminate accumulated SGR debt, preventing a potential 21.5% cut in 2010 reimbursement fees. The more cost-conscious Senate Finance bill, by contrast, provides a one-year patch, providing a 0.5% update instead of any cut, but it leaves the SGR in place. “We understand the budgetary constraints that Senator Baucus is working with, but we’re disappointed that the SGR is getting another patch,” says Eric Siegal, MD, FHM, chair of SHM’s Public Policy Committee. “If we’re going to talk about restructuring healthcare, then we also need a payment system that is stable and that is not subject to the yearly whims of Congress.”

2. Medical Liability Reform

The Senate Finance plan’s nonbinding “Sense of the Senate,” which encourages states to pursue alternatives to the current civil litigation system, is a “missed opportunity,” according to Dr. Siegal. “We think that the Senate Finance Committee should have gone further with this,” he says, noting that medical liability is a significant driver of unnecessary healthcare expenses. The House bill is more robust in pushing medical malpractice reform by offering states federal assistance, Dr. Siegal says, but still leaves room for improvement.

3. Primary-Care Bonus Payments

Conceptually, the Senate and the House bills offer similar proposals to improve reimbursements for primary care, something Dr. Siegal says SHM has consistently and strongly supported “as a way of preventing further erosion of the primary-care infrastructure.” Depending on how the Senate Finance plan defines “primary care,” hospitalists might benefit directly. “Even if you get past the issue of whether it hits our pocketbook favorably,” Dr. Siegal says, “it is in the strategic interest of our specialty to have a strong primary-care base.”

4. Bundled Payments

Proposals in both the Senate and House bills for a pilot program aimed at bundling payments around an episode of care have been greeted cautiously by hospitalists, as have other new payment proposals. Robust and meaningful demonstration projects, Dr. Siegal says, are necessary to get a better sense of what the consequences could be, intended or otherwise. “Any time you’re talking about changes to the fundamental architecture of how we pay people for what they do, you’d better spend some time looking into what the implications of that are,” he says. TH

Bryn Nelson is a freelance writer based in Seattle.

Image Sources: KASH76, DIADEMIMAGES, DAVID GUNN, TOMENG, ALEXEY KASHIN, JONATHAN LARSEN, JON HELGASON, STEFAN KLEIN, SX70, SDOMINICK/ISTOCKPHOTO.COM

The struggle over U.S. healthcare reform has consumed Congress for most of the year. It has dominated media coverage and fueled informal debates in all parts of the country. A resolution to the heated back-and-forth should arrive by Thanksgiving in the form of meaningful healthcare legislation, according to Vice President Joe Biden. Then again, Sen. Jim DeMint (R-S.C.) has pledged to cancel the Democrats’ planned festivities, preventing what he and other opponents have described as a “government takeover” of the healthcare system.

Amid the emotional tug-of-war and evolving bills, the nonpartisan Congressional Budget Office (CBO) has laid out the stakes. In a June letter to the Senate Budget Committee, CBO Director Douglas W. Elmendorf begins: “In the absence of significant changes in policy, rising costs for healthcare will cause federal spending to grow much faster than the economy, putting the federal budget on an unsustainable path.”

Most experts, analysts, and politicians agree that something must be done. It’s all a matter of what and how much it will cost. In the spirit of Thanksgiving, let’s talk turkey about the healthcare reform proposals that may or may not survive the holiday, and the key players who will determine whether this year’s reform effort stays alive—or gets stuffed.

Main Points of Disagreement

Whether healthcare reform should include a public option for a national insurance plan, smaller nonprofit co-ops, or nothing of the sort has dominated the debate over the competing proposals in Congress. But it’s hardly the only major disagreement.

Beyond the sticky matter of how to pay for everything, businesses instinctively have opposed any requirement that employers offer health insurance to their employees. Then again, that opposition seems to be softening as more details of the plan are released.

In principle, widespread agreement exists on the notion that individuals should have guaranteed issue and renewability of their healthcare insurance, regardless of pre-existing conditions. Far less clear, however, is the matter of how much those individuals will have to pay for their policies.

Main Points of Agreement

Not everyone is on board, but any healthcare reform bill that emerges from Congress is likely to contain three main elements, according to Leighton Ku, director of the Center for Health Policy Research at George Washington University in Washington, D.C.

1. Expansion of Medicaid

Details are still in flux, and some lawmakers have grumbled about the potential cost to states, but Ku says broad agreement exists for an expansion of Medicaid that would cover individuals and families who earn up to 133 percent or so of the federal poverty line. Estimates suggest that an additional 9 million uninsured, low-income adults could be covered. “That’s a huge swath right there that we can take out of the uninsured category,” he says.

2. Health Insurance Exchanges

Think of exchanges as the Travelocity or Orbitz for health-insurance plans, complete with coupons for the needy. Sliding-scale tax credits or vouchers could be used by low- to moderate-income people to buy insurance in publicly available, government-regulated marketplaces where such parameters as premiums and coverage could be compared. “The concept is that by setting up standards and having a place where it’s all together, it would create a competition,” Ku says.

In essence, more competition could lead to cost reductions.

3. An Individual Mandate

Hardship exemptions are likely, but people who can afford it will be expected to buy insurance or pay a penalty. Republican rumblings suggest that agreement on this point may not be as widespread as initially thought.

Main Players

President Obama has made healthcare reform the centerpiece of his first-year agenda. If he is to succeed, organizations like AARP will be key in winning over skeptical seniors. But the real power lies with a handful of Congressional leaders who have the ability to make or break any legislation. A brief rundown:

 

Senate

The illness and death of longtime healthcare reform advocate Sen. Edward Kennedy (D-Mass.) shifted the Congressional spotlight to Sen. Max Baucus (D-Mont.), right, chairman of the Senate Finance Committee and leader of the committee’s “Gang of Six” negotiators—three Democrats and three Republicans. In mid-September, Baucus unveiled his preliminary “mark” of the America’s Healthy Future Act. He did so without any Republican endorsement.

The overhaul is less expensive and more moderate than the America’s Affordable Health Choices Act, introduced in the House of Representatives, and a partial bill passed earlier by Sen. Kennedy’s Health, Education, Labor and Pensions (HELP) Committee. Nevertheless, progressives and conservatives criticized the Baucus plan. Even so, Sen. Olympia Snowe (R-Maine) has become a major focus of Democrats’ efforts to find 60 votes and avoid a Republican filibuster, though the seating of a replacement for Sen. Kennedy would help Democrats regain a filibuster-proof majority. One key point: Analysts say bringing Sen. Snowe on board might not win other Republican votes, but she might offer cover for such conservative Democratic senators as Mary Landrieu (D-La.) and Ben Nelson (D-Neb.).

As a last resort, Democrats have raised the possibility of using reconciliation, an arcane process originally intended for budgetary items. Reconciliation requires only a 51-vote majority, but complicated rules and a promised Republican challenge could lead to chaos.

House

Speaker Nancy Pelosi (D-Calif.), left, and Rep. Henry Waxman (D-Calif.) have dominated the stage, but they have had to balance the priorities of the chamber’s progressive wing with the concerns of the “Blue Dog” contingent of conservative Democrats.

Paying For It All

Meaningful reform without breaking the bank is a common refrain in healthcare discussions. Despite heated disputes over taxes, fees, fines, and service cuts to help defray costs, two main mechanisms for savings have emerged, according to the Center for Health Policy Research’s Ku:

1. Curbing Medicare Advantage

With the creation of Medicare drug benefits in 2003, Medicare’s managed-care plans run by private companies were revamped and renamed Medicare Advantage Plans. In return for extra benefits or lower co-payments, the 22% of Medicare beneficiaries enrolled in these plans are generally limited to in-network doctors or hospitals. Based on Medicare Payment Advisory Commission estimates, Medicare reimburses the private plans, on average, 14% more than standard Medicare fee-for-service plans—or an additional $12 billion in 2009.

One cost-cutting idea would be to restore a level playing field, Ku says, and pay managed care on par with Medicare and Medicaid. “This is one of the largest components of savings that people are anticipating,” he adds. A backlash by seniors, however, has led to a “grandfathering” clause that would protect the extra benefits in certain parts of the country, potentially reducing the overall savings.

2. Disproportionate Share Hospital (DSH) Cuts

Both Medicare and Medicaid pay extra to hospitals that serve a high proportion of needy patients. The savings mechanism here is less clear, but the expectation is that because the number of uninsured patients will drop dramatically with legislation, the DSH payments could be scaled back as well. The cuts, phased in over a decade, could amount to tens of billions of dollars in overall savings, though the House and Senate Finance bills differ in how deep the trims should be.

For More Information

• Kaiser Family Foundation
  

  http://healthreform.kff.org

  
  

  The foundation’s comprehensive “Health Reform” page offers a side-by-side comparison of 12 healthcare proposals, including both Democratic and Republican bills.

• Congressional Budget Office
  

  www.cbo.gov
  

  The nonpartisan office has already weighed in on the economic effects of preliminary versions of the competing healthcare reform bills, and will likely do so again.

• FactCheck.org
  

  A project of The University of Pennsylvania’s Annenberg Public Policy Center, the site has debunked dozens of healthcare reform myths.

• PolitiFact.com
  

  The Truth-O-Meter, a project of the St. Petersburg Times, has put recent healthcare assertions into categories ranging from “True” (substantiated assertions) to “Pants on Fire” (for absurd untruths).

• HospitalMedicine.org/advocacy
  

  SHM updates health reform progress and offers a monthly “Washington Update” outlining the society’s policy positions and activities.

 

Other Proposals to Keep an Eye On

• Addition of a hospital value-based purchasing (VBP) program to Medicare, which would tie incentive payments to performance on various quality measures;
• Expansion of the Physician’s Quality Reporting Initiative (PQRI), with a 1% payment penalty by 2012 for nonparticipants;
• Creation of a CMS payment innovation center to try out new payment structures, with the goal of improving quality and reducing Medicare costs; and
• Establishment of a Medicare pilot initiative called the Community Care Transitions Program, which would spend $500 million over 10 years on efforts to reduce preventable rehospitalizations; SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify.

Four Proposals Hospitalists Should Know About

1. Fixes to Medicare’s Physician Fee Schedule

The House bill would provide $228.5 billion to repeal the sustainable growth rate (SGR) used to determine the annual physician fee schedule and eliminate accumulated SGR debt, preventing a potential 21.5% cut in 2010 reimbursement fees. The more cost-conscious Senate Finance bill, by contrast, provides a one-year patch, providing a 0.5% update instead of any cut, but it leaves the SGR in place. “We understand the budgetary constraints that Senator Baucus is working with, but we’re disappointed that the SGR is getting another patch,” says Eric Siegal, MD, FHM, chair of SHM’s Public Policy Committee. “If we’re going to talk about restructuring healthcare, then we also need a payment system that is stable and that is not subject to the yearly whims of Congress.”

2. Medical Liability Reform

The Senate Finance plan’s nonbinding “Sense of the Senate,” which encourages states to pursue alternatives to the current civil litigation system, is a “missed opportunity,” according to Dr. Siegal. “We think that the Senate Finance Committee should have gone further with this,” he says, noting that medical liability is a significant driver of unnecessary healthcare expenses. The House bill is more robust in pushing medical malpractice reform by offering states federal assistance, Dr. Siegal says, but still leaves room for improvement.

3. Primary-Care Bonus Payments

Conceptually, the Senate and the House bills offer similar proposals to improve reimbursements for primary care, something Dr. Siegal says SHM has consistently and strongly supported “as a way of preventing further erosion of the primary-care infrastructure.” Depending on how the Senate Finance plan defines “primary care,” hospitalists might benefit directly. “Even if you get past the issue of whether it hits our pocketbook favorably,” Dr. Siegal says, “it is in the strategic interest of our specialty to have a strong primary-care base.”

4. Bundled Payments

Proposals in both the Senate and House bills for a pilot program aimed at bundling payments around an episode of care have been greeted cautiously by hospitalists, as have other new payment proposals. Robust and meaningful demonstration projects, Dr. Siegal says, are necessary to get a better sense of what the consequences could be, intended or otherwise. “Any time you’re talking about changes to the fundamental architecture of how we pay people for what they do, you’d better spend some time looking into what the implications of that are,” he says. TH

Bryn Nelson is a freelance writer based in Seattle.

Image Sources: KASH76, DIADEMIMAGES, DAVID GUNN, TOMENG, ALEXEY KASHIN, JONATHAN LARSEN, JON HELGASON, STEFAN KLEIN, SX70, SDOMINICK/ISTOCKPHOTO.COM

By now, if you’re a final-year resident, you should be thinking about your plans for when you finish your residency. Before you begin the job search in earnest, it’s a good idea to create or update your curriculum vitae, or CV. You might be thinking, “That’s easy. I haven’t done anything yet!” That might be the case, but in reality, you probably have done more than you realize.

Whether you are just starting out or need to freshen a rough draft, here are some recommendations for creating a CV.

Brainstorm

The first step is to capture all the things you have done. Start by taking a sheet of paper and making columns with the following headings: licensure/documents, honors and awards, presentations/publications, research activities, committees, teaching, community service, and special skills. List each of the things you’ve done in each category.

Don’t be modest. You have to sell yourself. No item is too small for consideration for your CV at this stage. Get together with other people in your residency class and brainstorm together. They might help you think of certain activities that you have not already thought about. Here are some key points to keep in mind as you brainstorm each section:

• Licensure/documents: If you haven’t obtained a license in the state where you want to practice, now is the time to do it. Make sure advanced cardiac life support (ACLS) and BLS are current. If you haven’t taken your board exam, mention that you are board-eligible and include the date you plan to take the exam.
Once you’ve created your first CV, you will need to develop a system to update and maintain the document. The easiest way to do this is to keep a “career folder” on your desktop or in a filing cabinet. This will help you catalog all the extra things you’ve done throughout your career.
• Honors and awards: You don’t have to receive a trophy at a fancy awards ceremony to fill out this section. Did you ever receive a letter from the department chair, program director, or clerkship director giving you a special commendation? Such recognition might be worth a mention.
• Presentations and publications: If you have been published, include the citation here. Many residents present posters at regional meetings; this information should go in your CV. Have you given a presentation for “Morning Report” or a “Morbidity and Mortality Conference”? If so, these count as presentations, too. Many residents have written Web-based materials. Cite these as well.
• Teaching: Consider all the activities you perform for medical students. Have you given the students any prepared lectures? Have you been a preceptor for their physical exam labs? Have you provided mentorship for a student? Significant time spent mentoring also should be reflected on a resident’s CV.
• Research: QI projects generally count as HM research projects.
• Committees: Think about all the meetings you’ve attended and determine if any of them count as providing services to the residency or hospital.
• Special skills: Proficiency in thoracocentesis or lumbar puncture procedures qualifies for this section. If you speak a second (or third, fourth, etc.) language, include it here.

 

Rough Draft = First Attempt

Now that you have gathered your information, it’s time to organize it. Web-based resources and templates are plentiful, and many can help you write the CV. If you are applying for an academic position, you will need to keep a detailed CV. If you are not applying for an academic position, it is best to keep your CV at no more than two pages in length; however, you might want to keep a comprehensive (and lengthier) version on file.

 

Maintain a Career Folder

Once you’ve created your first CV, you will need to develop a system to update and maintain the document. The easiest way to do this is to keep a “career folder” on your desktop or in a filing cabinet. This will help you catalog all the extra things you’ve done throughout your career.

Write notes to yourself, with the date and time spent on certain activities. Then, at regular intervals, document them on your CV. It’s best to update your CV every six months.

The career file also can be used to keep evaluations, letters from patients, or anything else that exemplifies your accomplishments at work. Having a system for organizing your achievements will help you negotiate a raise and assist with future promotions or tenure.

Cover Letter

A cover letter should be no more than three to four paragraphs in length. Keep it simple and to the point. Briefly state how you heard about the job opening and why you are interested in the job.

Take a paragraph to identify the skills and experience you have to offer the HM group. The final paragraph should be used to explain how you intend to follow up and the best way you can be reached (phone, e-mail, etc.) to arrange an interview.

Interview Tips

A well-written CV can lead to several interview offers. Here are some important tips to help you obtain that all-important job offer:

• Have a clear vision. It’s important to know what you are looking for. Having clear goals will help you know exactly the kind of job you want and avoid wasting time and energy.
• Set aside time for a phone interview. You can learn a lot about an HM program during this time; give the interviewer a chance to learn about you, too. Use this step to screen out those places you really want to visit in person.
• Show up on time. Give yourself enough time to reach your destination, park, and find the meeting location. If possible, take a test drive a day or two before.
• Remember, your appearance matters. Dress professionally in conservative business attire. Furthermore, always act professional. Avoid negative talk about past attendings or employers. If you are going out for lunch, avoid ordering alcohol.
• Write down questions to ask. This will give you more clarity and ensure that all of your questions regarding the prospective job are answered.
• Show interest in the program. Ask appropriate questions, even if you have all the information you need. Don’t leave without asking about the next steps in the hiring process.
• Talk about money last. Contrary to popular belief, it’s OK to bring up the topic of money during an interview. Just don’t make it your first—and only—question.
• Check out the town. Bring your spouse or partner to explore a prospective relocation site. Look into housing, schools, your potential commute, and recreational activities. TH

Dr. Garcia is assistant professor in the division of hospital medicine at the University of Texas Health Sciences Center at San Antonio. Dr. Patel is a hospitalist at HPMG Regions Hospital and assistant professor of medicine at the University of Minnesota in St. Paul.

Image Source: CHAGIN/ISTOCKPHOTO.COM

By now, if you’re a final-year resident, you should be thinking about your plans for when you finish your residency. Before you begin the job search in earnest, it’s a good idea to create or update your curriculum vitae, or CV. You might be thinking, “That’s easy. I haven’t done anything yet!” That might be the case, but in reality, you probably have done more than you realize.

Whether you are just starting out or need to freshen a rough draft, here are some recommendations for creating a CV.

Brainstorm

The first step is to capture all the things you have done. Start by taking a sheet of paper and making columns with the following headings: licensure/documents, honors and awards, presentations/publications, research activities, committees, teaching, community service, and special skills. List each of the things you’ve done in each category.

Don’t be modest. You have to sell yourself. No item is too small for consideration for your CV at this stage. Get together with other people in your residency class and brainstorm together. They might help you think of certain activities that you have not already thought about. Here are some key points to keep in mind as you brainstorm each section:

• Licensure/documents: If you haven’t obtained a license in the state where you want to practice, now is the time to do it. Make sure advanced cardiac life support (ACLS) and BLS are current. If you haven’t taken your board exam, mention that you are board-eligible and include the date you plan to take the exam.
Once you’ve created your first CV, you will need to develop a system to update and maintain the document. The easiest way to do this is to keep a “career folder” on your desktop or in a filing cabinet. This will help you catalog all the extra things you’ve done throughout your career.
• Honors and awards: You don’t have to receive a trophy at a fancy awards ceremony to fill out this section. Did you ever receive a letter from the department chair, program director, or clerkship director giving you a special commendation? Such recognition might be worth a mention.
• Presentations and publications: If you have been published, include the citation here. Many residents present posters at regional meetings; this information should go in your CV. Have you given a presentation for “Morning Report” or a “Morbidity and Mortality Conference”? If so, these count as presentations, too. Many residents have written Web-based materials. Cite these as well.
• Teaching: Consider all the activities you perform for medical students. Have you given the students any prepared lectures? Have you been a preceptor for their physical exam labs? Have you provided mentorship for a student? Significant time spent mentoring also should be reflected on a resident’s CV.
• Research: QI projects generally count as HM research projects.
• Committees: Think about all the meetings you’ve attended and determine if any of them count as providing services to the residency or hospital.
• Special skills: Proficiency in thoracocentesis or lumbar puncture procedures qualifies for this section. If you speak a second (or third, fourth, etc.) language, include it here.

 

Rough Draft = First Attempt

Now that you have gathered your information, it’s time to organize it. Web-based resources and templates are plentiful, and many can help you write the CV. If you are applying for an academic position, you will need to keep a detailed CV. If you are not applying for an academic position, it is best to keep your CV at no more than two pages in length; however, you might want to keep a comprehensive (and lengthier) version on file.

 

Maintain a Career Folder

Once you’ve created your first CV, you will need to develop a system to update and maintain the document. The easiest way to do this is to keep a “career folder” on your desktop or in a filing cabinet. This will help you catalog all the extra things you’ve done throughout your career.

Write notes to yourself, with the date and time spent on certain activities. Then, at regular intervals, document them on your CV. It’s best to update your CV every six months.

The career file also can be used to keep evaluations, letters from patients, or anything else that exemplifies your accomplishments at work. Having a system for organizing your achievements will help you negotiate a raise and assist with future promotions or tenure.

Cover Letter

A cover letter should be no more than three to four paragraphs in length. Keep it simple and to the point. Briefly state how you heard about the job opening and why you are interested in the job.

Take a paragraph to identify the skills and experience you have to offer the HM group. The final paragraph should be used to explain how you intend to follow up and the best way you can be reached (phone, e-mail, etc.) to arrange an interview.

Interview Tips

A well-written CV can lead to several interview offers. Here are some important tips to help you obtain that all-important job offer:

• Have a clear vision. It’s important to know what you are looking for. Having clear goals will help you know exactly the kind of job you want and avoid wasting time and energy.
• Set aside time for a phone interview. You can learn a lot about an HM program during this time; give the interviewer a chance to learn about you, too. Use this step to screen out those places you really want to visit in person.
• Show up on time. Give yourself enough time to reach your destination, park, and find the meeting location. If possible, take a test drive a day or two before.
• Remember, your appearance matters. Dress professionally in conservative business attire. Furthermore, always act professional. Avoid negative talk about past attendings or employers. If you are going out for lunch, avoid ordering alcohol.
• Write down questions to ask. This will give you more clarity and ensure that all of your questions regarding the prospective job are answered.
• Show interest in the program. Ask appropriate questions, even if you have all the information you need. Don’t leave without asking about the next steps in the hiring process.
• Talk about money last. Contrary to popular belief, it’s OK to bring up the topic of money during an interview. Just don’t make it your first—and only—question.
• Check out the town. Bring your spouse or partner to explore a prospective relocation site. Look into housing, schools, your potential commute, and recreational activities. TH

Dr. Garcia is assistant professor in the division of hospital medicine at the University of Texas Health Sciences Center at San Antonio. Dr. Patel is a hospitalist at HPMG Regions Hospital and assistant professor of medicine at the University of Minnesota in St. Paul.

Image Source: CHAGIN/ISTOCKPHOTO.COM

By now, if you’re a final-year resident, you should be thinking about your plans for when you finish your residency. Before you begin the job search in earnest, it’s a good idea to create or update your curriculum vitae, or CV. You might be thinking, “That’s easy. I haven’t done anything yet!” That might be the case, but in reality, you probably have done more than you realize.

Whether you are just starting out or need to freshen a rough draft, here are some recommendations for creating a CV.

Brainstorm

The first step is to capture all the things you have done. Start by taking a sheet of paper and making columns with the following headings: licensure/documents, honors and awards, presentations/publications, research activities, committees, teaching, community service, and special skills. List each of the things you’ve done in each category.

Don’t be modest. You have to sell yourself. No item is too small for consideration for your CV at this stage. Get together with other people in your residency class and brainstorm together. They might help you think of certain activities that you have not already thought about. Here are some key points to keep in mind as you brainstorm each section:

• Licensure/documents: If you haven’t obtained a license in the state where you want to practice, now is the time to do it. Make sure advanced cardiac life support (ACLS) and BLS are current. If you haven’t taken your board exam, mention that you are board-eligible and include the date you plan to take the exam.
Once you’ve created your first CV, you will need to develop a system to update and maintain the document. The easiest way to do this is to keep a “career folder” on your desktop or in a filing cabinet. This will help you catalog all the extra things you’ve done throughout your career.
• Honors and awards: You don’t have to receive a trophy at a fancy awards ceremony to fill out this section. Did you ever receive a letter from the department chair, program director, or clerkship director giving you a special commendation? Such recognition might be worth a mention.
• Presentations and publications: If you have been published, include the citation here. Many residents present posters at regional meetings; this information should go in your CV. Have you given a presentation for “Morning Report” or a “Morbidity and Mortality Conference”? If so, these count as presentations, too. Many residents have written Web-based materials. Cite these as well.
• Teaching: Consider all the activities you perform for medical students. Have you given the students any prepared lectures? Have you been a preceptor for their physical exam labs? Have you provided mentorship for a student? Significant time spent mentoring also should be reflected on a resident’s CV.
• Research: QI projects generally count as HM research projects.
• Committees: Think about all the meetings you’ve attended and determine if any of them count as providing services to the residency or hospital.
• Special skills: Proficiency in thoracocentesis or lumbar puncture procedures qualifies for this section. If you speak a second (or third, fourth, etc.) language, include it here.

 

Rough Draft = First Attempt

Now that you have gathered your information, it’s time to organize it. Web-based resources and templates are plentiful, and many can help you write the CV. If you are applying for an academic position, you will need to keep a detailed CV. If you are not applying for an academic position, it is best to keep your CV at no more than two pages in length; however, you might want to keep a comprehensive (and lengthier) version on file.

 

Maintain a Career Folder

Once you’ve created your first CV, you will need to develop a system to update and maintain the document. The easiest way to do this is to keep a “career folder” on your desktop or in a filing cabinet. This will help you catalog all the extra things you’ve done throughout your career.

Write notes to yourself, with the date and time spent on certain activities. Then, at regular intervals, document them on your CV. It’s best to update your CV every six months.

The career file also can be used to keep evaluations, letters from patients, or anything else that exemplifies your accomplishments at work. Having a system for organizing your achievements will help you negotiate a raise and assist with future promotions or tenure.

Cover Letter

A cover letter should be no more than three to four paragraphs in length. Keep it simple and to the point. Briefly state how you heard about the job opening and why you are interested in the job.

Take a paragraph to identify the skills and experience you have to offer the HM group. The final paragraph should be used to explain how you intend to follow up and the best way you can be reached (phone, e-mail, etc.) to arrange an interview.

Interview Tips

A well-written CV can lead to several interview offers. Here are some important tips to help you obtain that all-important job offer:

• Have a clear vision. It’s important to know what you are looking for. Having clear goals will help you know exactly the kind of job you want and avoid wasting time and energy.
• Set aside time for a phone interview. You can learn a lot about an HM program during this time; give the interviewer a chance to learn about you, too. Use this step to screen out those places you really want to visit in person.
• Show up on time. Give yourself enough time to reach your destination, park, and find the meeting location. If possible, take a test drive a day or two before.
• Remember, your appearance matters. Dress professionally in conservative business attire. Furthermore, always act professional. Avoid negative talk about past attendings or employers. If you are going out for lunch, avoid ordering alcohol.
• Write down questions to ask. This will give you more clarity and ensure that all of your questions regarding the prospective job are answered.
• Show interest in the program. Ask appropriate questions, even if you have all the information you need. Don’t leave without asking about the next steps in the hiring process.
• Talk about money last. Contrary to popular belief, it’s OK to bring up the topic of money during an interview. Just don’t make it your first—and only—question.
• Check out the town. Bring your spouse or partner to explore a prospective relocation site. Look into housing, schools, your potential commute, and recreational activities. TH

Dr. Garcia is assistant professor in the division of hospital medicine at the University of Texas Health Sciences Center at San Antonio. Dr. Patel is a hospitalist at HPMG Regions Hospital and assistant professor of medicine at the University of Minnesota in St. Paul.

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