Medicolegal Issues

The light at the end of the tunnel has arrived—finally. The long hours, scut work, and call nights have paid off; you’re an attending. The transition to the “real world” can be intimidating, especially when you’ve been in training for so long. Here are some tips to ease the transition.

1. Cultivate relationships. Your interactions with nurses, house staff, case managers, social workers, and your colleagues are even more important as an attending and will serve as the building blocks of your reputation. Diplomacy during times of conflict is invaluable. Your approach to resolving situations can further your career—or be a barrier to success.

In the beginning, you might be misidentified as a resident, so it’s important to introduce yourself and have regular conversations with colleagues and consultants until you are recognized and are on a first-name basis with them. Effective communication will go a long way with your patients, their families, and primary-care physicians (PCPs). The benefits of good communication include good Press Ganey patient satisfaction scores, less liability from lawsuits, safer hospital transitions and discharges, and a successful HM practice.

2. Learn the business of practice. The first year of practice will feature a steep learning curve in the areas of billing and documentation. Effective and appropriate billing is essential to maintaining the financial viability of a hospitalist group. Most HM groups provide formal training in billing and documentation as well as chart audits by billing experts. You may find it helpful to review “Billing and Coding” articles in The Hospitalist (also available at www.the-hospitalist.org).

Take time to learn business goals and areas in need of improvement, as this will allow you to improve individual and group performance. This may include maximizing pay for performance, improving hospital throughput by prioritizing discharges early in the morning, and reducing length of stay and readmission rates.

3. Seek work-life balance. Expect to be presented with multiple opportunities to get involved outside of your clinical duties. You could have the chance to participate in quality-improvement (QI) projects, teaching, hospital committees, and research. These activities will add to the depth of your curriculum vitae and give you a voice in hospital operations.

It’s important, however, to remember to pace yourself when you add duties outside the realm of your primary job responsibilities. Avoid spreading yourself too thin. As an attending, your work hours will be fewer and your salary will be better, but your responsibility will be greater. Be sure to set aside personal time and make job satisfaction a priority. More information is available in “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (www.hospitalmedicine.org/dashboard), which outlines the pillars of career satisfaction: autonomy/workflow, workload/schedule, reward/recognition, and community/ environment.

4. Stay current. In addition to reading prominent journals, such as the New England Journal of Medicine and the Journal of Hospital Medicine, look to newer resources that screen up-to-date literature for articles most relevant to hospitalists. American College of Physicians (ACP) members can sign up for ACP Journal Club Plus (acpjc.org), which provides periodic e-mail alerts when new articles meet customized quality and relevance filters. The Hospitalist has a monthly column, “In the Literature,” (see p. 9) that summarizes recent medical research. It also is important to understand how to find evidence-based information quickly. Familiarize yourself with Medline searches and pre-appraised literature resources, such as the Cochrane database, the print version of ACP Journal Club, and guidelines.gov.

5. Be efficient and thorough. Time-management skills are critical as an attending, especially when you’re being pulled in multiple directions. Develop a “to do” list to stay organized. When you are working with nurse practitioners, physician assistants, and residents, delegate certain duties to maximize your own efficiency. Their notes often can be used to assist with documentation, but remember to properly chart the clinical rationale for critical decisions and document medical stability on the day of patient discharge. Be sure you regularly review primary data, such as imaging, culture results, and consultant recommendations. Routinely communicate with PCPs—a prompt, real-time discharge summary is easiest when the information is fresh in your mind, and it ensures proper follow-up care.

6. Know help is available. Just because you’re not a trainee anymore doesn’t mean help isn’t available. Medicine is a constantly evolving field, and you will encounter novel disease states as well as changing diagnostics and therapeutics throughout your career. When you encounter a challenging case, use your colleagues as a sounding board for ideas. When you’re not sure what to do, consultants can be called to assist. Remember, you’re not there to impress others but to provide the best possible care for your patients. Sometimes that means obtaining the advice of a specialist.

If you practice with physician extenders or house staff, you’ll find it helpful to occasionally speak directly to the attending consultant. This helps promote collegial relationships, gives consultants a better understanding of your concerns, and improves your own base of knowledge.

7. Use supervisory skills. If you are practicing in an academic setting or one with physician extenders, you will want to be readily accessible to house staff, physician assistants, and nurse practitioners under your supervision. When you first greet a patient, be sure to clearly identify yourself as the attending physician. At the same time, afford trainees the opportunity to experience being the physician—allow them to actively participate in decision-making, reinforcing best-practice and evidence-based principles as you teach.

8. Understand licensing and certification. Understand your state’s policies and start the licensing process right away, especially if your first job is in a state other than where you completed residency. For most hospitalists, this means taking the medicine boards, then a recertification exam every 10 years, as well as regularly completing continuing medical education (CME). For those looking for a promotion down the line, familiarize yourself with the culture and selection criteria of your individual hospital or group. TH

Dr. Huang is assistant clinical professor in the department of hospital medicine at the University of California San Diego Department of Medicine. Dr. Patel is associate director of hospitalist services at Staten Island University Hospital and assistant clinical professor of medicine at SUNY-Brooklyn. Dr. Chacko is a member of SHM’s Young Physician Committee and medical director of the hospitalist program at Preferred Health Partners in New York City.

The light at the end of the tunnel has arrived—finally. The long hours, scut work, and call nights have paid off; you’re an attending. The transition to the “real world” can be intimidating, especially when you’ve been in training for so long. Here are some tips to ease the transition.

1. Cultivate relationships. Your interactions with nurses, house staff, case managers, social workers, and your colleagues are even more important as an attending and will serve as the building blocks of your reputation. Diplomacy during times of conflict is invaluable. Your approach to resolving situations can further your career—or be a barrier to success.

In the beginning, you might be misidentified as a resident, so it’s important to introduce yourself and have regular conversations with colleagues and consultants until you are recognized and are on a first-name basis with them. Effective communication will go a long way with your patients, their families, and primary-care physicians (PCPs). The benefits of good communication include good Press Ganey patient satisfaction scores, less liability from lawsuits, safer hospital transitions and discharges, and a successful HM practice.

2. Learn the business of practice. The first year of practice will feature a steep learning curve in the areas of billing and documentation. Effective and appropriate billing is essential to maintaining the financial viability of a hospitalist group. Most HM groups provide formal training in billing and documentation as well as chart audits by billing experts. You may find it helpful to review “Billing and Coding” articles in The Hospitalist (also available at www.the-hospitalist.org).

Take time to learn business goals and areas in need of improvement, as this will allow you to improve individual and group performance. This may include maximizing pay for performance, improving hospital throughput by prioritizing discharges early in the morning, and reducing length of stay and readmission rates.

3. Seek work-life balance. Expect to be presented with multiple opportunities to get involved outside of your clinical duties. You could have the chance to participate in quality-improvement (QI) projects, teaching, hospital committees, and research. These activities will add to the depth of your curriculum vitae and give you a voice in hospital operations.

It’s important, however, to remember to pace yourself when you add duties outside the realm of your primary job responsibilities. Avoid spreading yourself too thin. As an attending, your work hours will be fewer and your salary will be better, but your responsibility will be greater. Be sure to set aside personal time and make job satisfaction a priority. More information is available in “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (www.hospitalmedicine.org/dashboard), which outlines the pillars of career satisfaction: autonomy/workflow, workload/schedule, reward/recognition, and community/ environment.

4. Stay current. In addition to reading prominent journals, such as the New England Journal of Medicine and the Journal of Hospital Medicine, look to newer resources that screen up-to-date literature for articles most relevant to hospitalists. American College of Physicians (ACP) members can sign up for ACP Journal Club Plus (acpjc.org), which provides periodic e-mail alerts when new articles meet customized quality and relevance filters. The Hospitalist has a monthly column, “In the Literature,” (see p. 9) that summarizes recent medical research. It also is important to understand how to find evidence-based information quickly. Familiarize yourself with Medline searches and pre-appraised literature resources, such as the Cochrane database, the print version of ACP Journal Club, and guidelines.gov.

5. Be efficient and thorough. Time-management skills are critical as an attending, especially when you’re being pulled in multiple directions. Develop a “to do” list to stay organized. When you are working with nurse practitioners, physician assistants, and residents, delegate certain duties to maximize your own efficiency. Their notes often can be used to assist with documentation, but remember to properly chart the clinical rationale for critical decisions and document medical stability on the day of patient discharge. Be sure you regularly review primary data, such as imaging, culture results, and consultant recommendations. Routinely communicate with PCPs—a prompt, real-time discharge summary is easiest when the information is fresh in your mind, and it ensures proper follow-up care.

6. Know help is available. Just because you’re not a trainee anymore doesn’t mean help isn’t available. Medicine is a constantly evolving field, and you will encounter novel disease states as well as changing diagnostics and therapeutics throughout your career. When you encounter a challenging case, use your colleagues as a sounding board for ideas. When you’re not sure what to do, consultants can be called to assist. Remember, you’re not there to impress others but to provide the best possible care for your patients. Sometimes that means obtaining the advice of a specialist.

If you practice with physician extenders or house staff, you’ll find it helpful to occasionally speak directly to the attending consultant. This helps promote collegial relationships, gives consultants a better understanding of your concerns, and improves your own base of knowledge.

7. Use supervisory skills. If you are practicing in an academic setting or one with physician extenders, you will want to be readily accessible to house staff, physician assistants, and nurse practitioners under your supervision. When you first greet a patient, be sure to clearly identify yourself as the attending physician. At the same time, afford trainees the opportunity to experience being the physician—allow them to actively participate in decision-making, reinforcing best-practice and evidence-based principles as you teach.

8. Understand licensing and certification. Understand your state’s policies and start the licensing process right away, especially if your first job is in a state other than where you completed residency. For most hospitalists, this means taking the medicine boards, then a recertification exam every 10 years, as well as regularly completing continuing medical education (CME). For those looking for a promotion down the line, familiarize yourself with the culture and selection criteria of your individual hospital or group. TH

Dr. Huang is assistant clinical professor in the department of hospital medicine at the University of California San Diego Department of Medicine. Dr. Patel is associate director of hospitalist services at Staten Island University Hospital and assistant clinical professor of medicine at SUNY-Brooklyn. Dr. Chacko is a member of SHM’s Young Physician Committee and medical director of the hospitalist program at Preferred Health Partners in New York City.

The light at the end of the tunnel has arrived—finally. The long hours, scut work, and call nights have paid off; you’re an attending. The transition to the “real world” can be intimidating, especially when you’ve been in training for so long. Here are some tips to ease the transition.

1. Cultivate relationships. Your interactions with nurses, house staff, case managers, social workers, and your colleagues are even more important as an attending and will serve as the building blocks of your reputation. Diplomacy during times of conflict is invaluable. Your approach to resolving situations can further your career—or be a barrier to success.

In the beginning, you might be misidentified as a resident, so it’s important to introduce yourself and have regular conversations with colleagues and consultants until you are recognized and are on a first-name basis with them. Effective communication will go a long way with your patients, their families, and primary-care physicians (PCPs). The benefits of good communication include good Press Ganey patient satisfaction scores, less liability from lawsuits, safer hospital transitions and discharges, and a successful HM practice.

2. Learn the business of practice. The first year of practice will feature a steep learning curve in the areas of billing and documentation. Effective and appropriate billing is essential to maintaining the financial viability of a hospitalist group. Most HM groups provide formal training in billing and documentation as well as chart audits by billing experts. You may find it helpful to review “Billing and Coding” articles in The Hospitalist (also available at www.the-hospitalist.org).

Take time to learn business goals and areas in need of improvement, as this will allow you to improve individual and group performance. This may include maximizing pay for performance, improving hospital throughput by prioritizing discharges early in the morning, and reducing length of stay and readmission rates.

3. Seek work-life balance. Expect to be presented with multiple opportunities to get involved outside of your clinical duties. You could have the chance to participate in quality-improvement (QI) projects, teaching, hospital committees, and research. These activities will add to the depth of your curriculum vitae and give you a voice in hospital operations.

It’s important, however, to remember to pace yourself when you add duties outside the realm of your primary job responsibilities. Avoid spreading yourself too thin. As an attending, your work hours will be fewer and your salary will be better, but your responsibility will be greater. Be sure to set aside personal time and make job satisfaction a priority. More information is available in “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (www.hospitalmedicine.org/dashboard), which outlines the pillars of career satisfaction: autonomy/workflow, workload/schedule, reward/recognition, and community/ environment.

4. Stay current. In addition to reading prominent journals, such as the New England Journal of Medicine and the Journal of Hospital Medicine, look to newer resources that screen up-to-date literature for articles most relevant to hospitalists. American College of Physicians (ACP) members can sign up for ACP Journal Club Plus (acpjc.org), which provides periodic e-mail alerts when new articles meet customized quality and relevance filters. The Hospitalist has a monthly column, “In the Literature,” (see p. 9) that summarizes recent medical research. It also is important to understand how to find evidence-based information quickly. Familiarize yourself with Medline searches and pre-appraised literature resources, such as the Cochrane database, the print version of ACP Journal Club, and guidelines.gov.

5. Be efficient and thorough. Time-management skills are critical as an attending, especially when you’re being pulled in multiple directions. Develop a “to do” list to stay organized. When you are working with nurse practitioners, physician assistants, and residents, delegate certain duties to maximize your own efficiency. Their notes often can be used to assist with documentation, but remember to properly chart the clinical rationale for critical decisions and document medical stability on the day of patient discharge. Be sure you regularly review primary data, such as imaging, culture results, and consultant recommendations. Routinely communicate with PCPs—a prompt, real-time discharge summary is easiest when the information is fresh in your mind, and it ensures proper follow-up care.

6. Know help is available. Just because you’re not a trainee anymore doesn’t mean help isn’t available. Medicine is a constantly evolving field, and you will encounter novel disease states as well as changing diagnostics and therapeutics throughout your career. When you encounter a challenging case, use your colleagues as a sounding board for ideas. When you’re not sure what to do, consultants can be called to assist. Remember, you’re not there to impress others but to provide the best possible care for your patients. Sometimes that means obtaining the advice of a specialist.

If you practice with physician extenders or house staff, you’ll find it helpful to occasionally speak directly to the attending consultant. This helps promote collegial relationships, gives consultants a better understanding of your concerns, and improves your own base of knowledge.

7. Use supervisory skills. If you are practicing in an academic setting or one with physician extenders, you will want to be readily accessible to house staff, physician assistants, and nurse practitioners under your supervision. When you first greet a patient, be sure to clearly identify yourself as the attending physician. At the same time, afford trainees the opportunity to experience being the physician—allow them to actively participate in decision-making, reinforcing best-practice and evidence-based principles as you teach.

8. Understand licensing and certification. Understand your state’s policies and start the licensing process right away, especially if your first job is in a state other than where you completed residency. For most hospitalists, this means taking the medicine boards, then a recertification exam every 10 years, as well as regularly completing continuing medical education (CME). For those looking for a promotion down the line, familiarize yourself with the culture and selection criteria of your individual hospital or group. TH

Dr. Huang is assistant clinical professor in the department of hospital medicine at the University of California San Diego Department of Medicine. Dr. Patel is associate director of hospitalist services at Staten Island University Hospital and assistant clinical professor of medicine at SUNY-Brooklyn. Dr. Chacko is a member of SHM’s Young Physician Committee and medical director of the hospitalist program at Preferred Health Partners in New York City.

A mystery. That’s what MedPAC is to many hospitalists. You might recognize the name from communications about Medicare’s physician fee schedule, but what is this entity, what power does it possess, and how does it affect the work you do and the pay you receive?

MedPAC is the Medicare Payment Advisory Commission, an independent agency established by the Balanced Budget Act of 1997. Its mission is to advise Congress on issues affecting Medicare, including payments to private health plans participating in Medicare as well as providers in Medicare’s traditional fee-for-service program. MedPAC also analyzes and advises legislators on two issues on HM’s radar: access to care and quality of care.

Ear of the Law

Why is MedPAC important to hospitalists? Money. The commission advises Congress on how Medicare is going to pay for healthcare services, and Medicare is a major payor for any hospitalist, says Ron Greeno, MD, FHM, chief medical officer of Cogent Healthcare in Irvine, Calif., and a member of SHM’s Public Policy Committee. “The majority of patients we’ll be taking care of in any hospital are Medicare patients,” he says, “and it’s not just how we get paid, but all the regulations around that. … MedPAC will weigh in on that and certainly shape the thinking of lawmakers.”

“MedPAC is about payment … but obviously there are other policy issues they weigh in on,” Dr. Greeno says. For example, MedPAC makes specific recommendations on the physician fee schedule and determines how hospitalists document and code.

How It Works

The commission is made up of 17 volunteer members from a diverse spectrum of healthcare backgrounds. Commissioners are appointed to three-year renewable terms. An executive director and staff of analysts with backgrounds in economics, health policy, public health, and medicine support the agency.

MedPAC holds monthly public meetings in Washington, D.C., to discuss Medicare issues and policy questions, and to formulate recommendations to Congress. Meetings include research presentations by MedPAC staff, policy experts, and interested parties. Each meeting allows time for public comment.

The commission provides its recommendations to Congress in biannual reports, issued in March and June. MedPAC also advises Congress through comment on reports and proposed regulations issued by the U.S. Department of Health and Human Services (HHS), testimony, and briefings for congressional staff.

A New Role

This year, as President Obama and his administration push for rapid and major healthcare changes, Dr. Greeno says MedPAC’s role will shift as Congress speeds toward new solutions. “How things are going to get done is already different than it was last year,” he says. “The pace of the government’s attempts to change how Medicare looks has picked up considerably.”

Citing SHM’s Public Policy Committee meetings with lawmakers in March, Dr. Greeno says healthcare reform is on the fast track. “Everything we were hearing from CMS [Centers for Medicare and Medicaid Services], the American Hospital Association, and MedPAC indicated that they’re looking to have a healthcare reform bill to Congress by summer,” he says. “When you have that kind of pace, things will come from a lot of different areas.”

Dr. Greeno uses pay for performance as one example of how government can be slow to change healthcare policy. “That process has taken years, but it’s still a small percentage of how we’re paid,” Dr. Greeno says, noting the current administration has expressed interest in changing course on the policy. “Now we may have complete reform of Medicare payments. In light of the rapidness of this pace, I’m not sure MedPAC’s role will be the same. They’ll continue to be a resource to Congress, but the commissioners are volunteers with full-time jobs; they meet once a month, while legislation is being worked on pretty much around the clock right now.”

MedPAC Sets the Tone

Even if the commission isn’t prepared to make direct recommendations for new legislation in the next few months, it still has significant influence. Since its inception, MedPac has routinely “set the tone” for policy reform, Dr. Greeno stresses. “For example, the healthcare reform legislation will likely include bundling payments to hospitals and physicians who work in hospitals,” he says. “MedPAC has already made recommendations to do this, as well as to start demonstration projects.” Earlier this year, sites were selected for Medicare’s Acute Care Episode (ACE) demonstration, under which a single global payment will be made for inpatient facility and professional services. “The same is true of the idea of paying based on quality, not patient volume,” Dr. Greeno says. “The commission has made recommendations on this.”

Then again, no one can say how the future of healthcare reform will unfold, or how quickly things will move this year. “The healthcare bill introduced this summer could completely do away with fee-for-service payments,” Dr. Greeno says. “Of course, nobody knows when—or if—that bill will get passed.” TH

Jane Jerrard is a medical writer based in Chicago.

A mystery. That’s what MedPAC is to many hospitalists. You might recognize the name from communications about Medicare’s physician fee schedule, but what is this entity, what power does it possess, and how does it affect the work you do and the pay you receive?

MedPAC is the Medicare Payment Advisory Commission, an independent agency established by the Balanced Budget Act of 1997. Its mission is to advise Congress on issues affecting Medicare, including payments to private health plans participating in Medicare as well as providers in Medicare’s traditional fee-for-service program. MedPAC also analyzes and advises legislators on two issues on HM’s radar: access to care and quality of care.

Ear of the Law

Why is MedPAC important to hospitalists? Money. The commission advises Congress on how Medicare is going to pay for healthcare services, and Medicare is a major payor for any hospitalist, says Ron Greeno, MD, FHM, chief medical officer of Cogent Healthcare in Irvine, Calif., and a member of SHM’s Public Policy Committee. “The majority of patients we’ll be taking care of in any hospital are Medicare patients,” he says, “and it’s not just how we get paid, but all the regulations around that. … MedPAC will weigh in on that and certainly shape the thinking of lawmakers.”

“MedPAC is about payment … but obviously there are other policy issues they weigh in on,” Dr. Greeno says. For example, MedPAC makes specific recommendations on the physician fee schedule and determines how hospitalists document and code.

How It Works

The commission is made up of 17 volunteer members from a diverse spectrum of healthcare backgrounds. Commissioners are appointed to three-year renewable terms. An executive director and staff of analysts with backgrounds in economics, health policy, public health, and medicine support the agency.

MedPAC holds monthly public meetings in Washington, D.C., to discuss Medicare issues and policy questions, and to formulate recommendations to Congress. Meetings include research presentations by MedPAC staff, policy experts, and interested parties. Each meeting allows time for public comment.

The commission provides its recommendations to Congress in biannual reports, issued in March and June. MedPAC also advises Congress through comment on reports and proposed regulations issued by the U.S. Department of Health and Human Services (HHS), testimony, and briefings for congressional staff.

A New Role

This year, as President Obama and his administration push for rapid and major healthcare changes, Dr. Greeno says MedPAC’s role will shift as Congress speeds toward new solutions. “How things are going to get done is already different than it was last year,” he says. “The pace of the government’s attempts to change how Medicare looks has picked up considerably.”

Citing SHM’s Public Policy Committee meetings with lawmakers in March, Dr. Greeno says healthcare reform is on the fast track. “Everything we were hearing from CMS [Centers for Medicare and Medicaid Services], the American Hospital Association, and MedPAC indicated that they’re looking to have a healthcare reform bill to Congress by summer,” he says. “When you have that kind of pace, things will come from a lot of different areas.”

Dr. Greeno uses pay for performance as one example of how government can be slow to change healthcare policy. “That process has taken years, but it’s still a small percentage of how we’re paid,” Dr. Greeno says, noting the current administration has expressed interest in changing course on the policy. “Now we may have complete reform of Medicare payments. In light of the rapidness of this pace, I’m not sure MedPAC’s role will be the same. They’ll continue to be a resource to Congress, but the commissioners are volunteers with full-time jobs; they meet once a month, while legislation is being worked on pretty much around the clock right now.”

MedPAC Sets the Tone

Even if the commission isn’t prepared to make direct recommendations for new legislation in the next few months, it still has significant influence. Since its inception, MedPac has routinely “set the tone” for policy reform, Dr. Greeno stresses. “For example, the healthcare reform legislation will likely include bundling payments to hospitals and physicians who work in hospitals,” he says. “MedPAC has already made recommendations to do this, as well as to start demonstration projects.” Earlier this year, sites were selected for Medicare’s Acute Care Episode (ACE) demonstration, under which a single global payment will be made for inpatient facility and professional services. “The same is true of the idea of paying based on quality, not patient volume,” Dr. Greeno says. “The commission has made recommendations on this.”

Then again, no one can say how the future of healthcare reform will unfold, or how quickly things will move this year. “The healthcare bill introduced this summer could completely do away with fee-for-service payments,” Dr. Greeno says. “Of course, nobody knows when—or if—that bill will get passed.” TH

Jane Jerrard is a medical writer based in Chicago.

A mystery. That’s what MedPAC is to many hospitalists. You might recognize the name from communications about Medicare’s physician fee schedule, but what is this entity, what power does it possess, and how does it affect the work you do and the pay you receive?

MedPAC is the Medicare Payment Advisory Commission, an independent agency established by the Balanced Budget Act of 1997. Its mission is to advise Congress on issues affecting Medicare, including payments to private health plans participating in Medicare as well as providers in Medicare’s traditional fee-for-service program. MedPAC also analyzes and advises legislators on two issues on HM’s radar: access to care and quality of care.

Ear of the Law

Why is MedPAC important to hospitalists? Money. The commission advises Congress on how Medicare is going to pay for healthcare services, and Medicare is a major payor for any hospitalist, says Ron Greeno, MD, FHM, chief medical officer of Cogent Healthcare in Irvine, Calif., and a member of SHM’s Public Policy Committee. “The majority of patients we’ll be taking care of in any hospital are Medicare patients,” he says, “and it’s not just how we get paid, but all the regulations around that. … MedPAC will weigh in on that and certainly shape the thinking of lawmakers.”

“MedPAC is about payment … but obviously there are other policy issues they weigh in on,” Dr. Greeno says. For example, MedPAC makes specific recommendations on the physician fee schedule and determines how hospitalists document and code.

How It Works

The commission is made up of 17 volunteer members from a diverse spectrum of healthcare backgrounds. Commissioners are appointed to three-year renewable terms. An executive director and staff of analysts with backgrounds in economics, health policy, public health, and medicine support the agency.

MedPAC holds monthly public meetings in Washington, D.C., to discuss Medicare issues and policy questions, and to formulate recommendations to Congress. Meetings include research presentations by MedPAC staff, policy experts, and interested parties. Each meeting allows time for public comment.

The commission provides its recommendations to Congress in biannual reports, issued in March and June. MedPAC also advises Congress through comment on reports and proposed regulations issued by the U.S. Department of Health and Human Services (HHS), testimony, and briefings for congressional staff.

A New Role

This year, as President Obama and his administration push for rapid and major healthcare changes, Dr. Greeno says MedPAC’s role will shift as Congress speeds toward new solutions. “How things are going to get done is already different than it was last year,” he says. “The pace of the government’s attempts to change how Medicare looks has picked up considerably.”

Citing SHM’s Public Policy Committee meetings with lawmakers in March, Dr. Greeno says healthcare reform is on the fast track. “Everything we were hearing from CMS [Centers for Medicare and Medicaid Services], the American Hospital Association, and MedPAC indicated that they’re looking to have a healthcare reform bill to Congress by summer,” he says. “When you have that kind of pace, things will come from a lot of different areas.”

Dr. Greeno uses pay for performance as one example of how government can be slow to change healthcare policy. “That process has taken years, but it’s still a small percentage of how we’re paid,” Dr. Greeno says, noting the current administration has expressed interest in changing course on the policy. “Now we may have complete reform of Medicare payments. In light of the rapidness of this pace, I’m not sure MedPAC’s role will be the same. They’ll continue to be a resource to Congress, but the commissioners are volunteers with full-time jobs; they meet once a month, while legislation is being worked on pretty much around the clock right now.”

MedPAC Sets the Tone

Even if the commission isn’t prepared to make direct recommendations for new legislation in the next few months, it still has significant influence. Since its inception, MedPac has routinely “set the tone” for policy reform, Dr. Greeno stresses. “For example, the healthcare reform legislation will likely include bundling payments to hospitals and physicians who work in hospitals,” he says. “MedPAC has already made recommendations to do this, as well as to start demonstration projects.” Earlier this year, sites were selected for Medicare’s Acute Care Episode (ACE) demonstration, under which a single global payment will be made for inpatient facility and professional services. “The same is true of the idea of paying based on quality, not patient volume,” Dr. Greeno says. “The commission has made recommendations on this.”

Then again, no one can say how the future of healthcare reform will unfold, or how quickly things will move this year. “The healthcare bill introduced this summer could completely do away with fee-for-service payments,” Dr. Greeno says. “Of course, nobody knows when—or if—that bill will get passed.” TH

Jane Jerrard is a medical writer based in Chicago.

Let’s look at a case: A known diabetic patient has been in good control, with glycosylated hemoglobin (HbA1c) levels lower than 6.5 gm/dL the past two years. Her medication regimen has remained relatively stable during that time. Her daily medications include simvastatin, 40 mg; metformin extended release, 2,000 mg; sitagliptin, 100 mg; glimepiride, 8 mg; quinapril, 20 mg; a multivitamin; calcium carbonate, 1,500 mg; and an 81-mg aspirin.

Her lipid panel, liver and renal function tests, and blood pressure are all within normal limits. However, she was admitted to the hospital with a plasma glucose level of 38 mg/dL.

Upon physical examination, she appears diaphoretic, with weakness, confusion, tremulousness, and palpitations. She is treated with glucose to maintain a level of above 50 mg/dL, and she responds without long-term sequelae.

What precipitated this event?

Drug-Induced Hypoglycemia

Hypoglycemia may represent a lab error or artifactual hypoglycemia due to glycolysis in the collection sample. To determine a pathological cause of hypoglycemia, the triad of low plasma glucose, hypoglycemia symptoms, and symptom resolution with correction of the blood glucose level should be used.1 Hypoglycemia is most often seen in diabetic patients and is the most commonly noted endocrine emergency in the inpatient setting, as well as in the ambulatory setting. Some common causes of hypoglycemia in diabetes patients include alcohol consumption, skipping meals, too much exercise, and intentional or unintentional medication overdoses.2

Treatment is required when the blood glucose level is below 45 gm/dL. Symptoms include anxiety, tremulousness, nausea, sweating, palpitation, and hunger.3 More severe symptoms related to compromised central nervous system function include weakness, fatigue, confusion, seizures, focal neurologic deficits, and coma.

The most common causes of drug-induced hypoglycemia are insulin, ethanol, or sulfonylureas. Risk factors associated with unintentional overdose of sulfonylureas include advanced age, drug-to-drug interactions, and decreased renal or hepatic clearance. Other drugs have been reported to cause hypoglycemia. Some of these include high-dose salicylates, beta-blockers, haloperidol, monoamine oxidase inhibitors, other sulfonamides (particularly trimethoprim-sulfamethoxazole), pentamidine, quinine/quinidine, and quinolone antibiotics (e.g., gatifloxacin or levofloxacin).4

Diabetics use more than 120 natural medicines, either alone or in combination with their prescribed diabetes medications, to lower blood glucose and/or improve HbA1c.5 Some of the most commonly used products are banaba, bitter melon, fenugreek, and Gymnema (hypoglycemics), along with American or panax ginseng, cassia cinnamon, chromium, prickly pear cactus, soy, or vanadium (insulin sensitizers).

Diagnosis

Patient history aids in the clinical diagnosis of hypoglycemia and should be reviewed to determine a potential drug-induced cause. History also might identify a medication dispensing error (e.g., the onset of hypoglycemia following a recent medication refill). Hospitalists should question the patient or the patient’s family as to medication use, including over-the-counter drugs, vitamins, supplements, natural foods, and other related products.

Treatment

Glucose should be administered to maintain a plasma glucose level of at least 50 gm/dL. This may be achieved orally via frequent meals or snacks, or intravenously. The underlying cause should be addressed. In drug- or medication-induced cases, the causative agent should be removed or retitrated to an effective dose that does not cause hypoglycemia.

Upon further questioning, the patient admitted she’d been taking 3,000 mg of a bitter melon product per day. She took this in addition to all her prescribed medications. Because bitter melon has an insulin-like effect, its use in combination with glimepiride led to the clinically significant hypoglycemic reaction, which required hospitalization and treatment. Prior to discharge, the patient promised to discuss the use of alternative and natural products with her pharmacist or physician before trying anything new. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City.

References

1. Guettier JM, Gorden P. Hypoglycemia. Endocrinol Metab Clin North Am. 2006;35:753-766.
2. Holt HH. Drug-induced hypoglycemia: overview. The University of Maryland Medical Center Web site. Available at: www.umm.edu/ency/article/000310.htm. Accessed March 2, 2009.
3. Hurd R. Drug-induced hypoglycemia. Drugs.com Web site. Available at: www.drugs.com/enc/drug-induced-hypoglycemia.html. Accessed March 2, 2009.
4. Mehlhorn AJ, Brown DA. Safety concerns with fluoroquinolones. Ann Pharmacother. 2007; 41:1859-1866.
5. Natural medicines in the clinical management of diabetes. Natural Medicines Comprehensive Database Web site. Available at: www.naturaldatabase.com. Accessed March 3, 2009.
6. Teva announces approval and launch of generic Imitrex tablets. Available at: finance.yahoo.com/news/Teva-Announces-Approval-and-bw-14308223.html/print. Accessed March 2, 2009.
7. Additional strengths of Avinza available. Monthly Prescribing Reference Web site. Available at: www.empr.com/Additional-strengths-of-Avinza-available/article/126905/. Accessed March 2, 2009.
8. Gelnique treatment for overactive bladder. Drugs.com Web site. Available at: www.drugs.com/gelnique.html. Accessed March 2, 2009.
9. Reclast label. The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/cder/foi/label/2008/021817s002lbl.pdf. Accessed March 2, 2009.
10. Clopidogrel bisulfate (marketed as Plavix). The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/medwatch/safety/2009/safety09.htm#plavix. Accessed March 2, 2009.
11. PPI interactions with clopidogrel. Med Lett Drugs Ther. 2009;51 (1303):2-3.
12. PPI interactions with clopidogrel revisited. Med Lett Drugs Ther. 2009;51(1306):13-4.
13. Xigris (Drotrecogin alfa [activated]): early communication about an ongoing safety review. The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/medwatch/safety/2009/safety09.htm#Xigris. Accessed March 2, 2009.

Let’s look at a case: A known diabetic patient has been in good control, with glycosylated hemoglobin (HbA1c) levels lower than 6.5 gm/dL the past two years. Her medication regimen has remained relatively stable during that time. Her daily medications include simvastatin, 40 mg; metformin extended release, 2,000 mg; sitagliptin, 100 mg; glimepiride, 8 mg; quinapril, 20 mg; a multivitamin; calcium carbonate, 1,500 mg; and an 81-mg aspirin.

Her lipid panel, liver and renal function tests, and blood pressure are all within normal limits. However, she was admitted to the hospital with a plasma glucose level of 38 mg/dL.

Upon physical examination, she appears diaphoretic, with weakness, confusion, tremulousness, and palpitations. She is treated with glucose to maintain a level of above 50 mg/dL, and she responds without long-term sequelae.

What precipitated this event?

Drug-Induced Hypoglycemia

Hypoglycemia may represent a lab error or artifactual hypoglycemia due to glycolysis in the collection sample. To determine a pathological cause of hypoglycemia, the triad of low plasma glucose, hypoglycemia symptoms, and symptom resolution with correction of the blood glucose level should be used.1 Hypoglycemia is most often seen in diabetic patients and is the most commonly noted endocrine emergency in the inpatient setting, as well as in the ambulatory setting. Some common causes of hypoglycemia in diabetes patients include alcohol consumption, skipping meals, too much exercise, and intentional or unintentional medication overdoses.2

Treatment is required when the blood glucose level is below 45 gm/dL. Symptoms include anxiety, tremulousness, nausea, sweating, palpitation, and hunger.3 More severe symptoms related to compromised central nervous system function include weakness, fatigue, confusion, seizures, focal neurologic deficits, and coma.

The most common causes of drug-induced hypoglycemia are insulin, ethanol, or sulfonylureas. Risk factors associated with unintentional overdose of sulfonylureas include advanced age, drug-to-drug interactions, and decreased renal or hepatic clearance. Other drugs have been reported to cause hypoglycemia. Some of these include high-dose salicylates, beta-blockers, haloperidol, monoamine oxidase inhibitors, other sulfonamides (particularly trimethoprim-sulfamethoxazole), pentamidine, quinine/quinidine, and quinolone antibiotics (e.g., gatifloxacin or levofloxacin).4

Diabetics use more than 120 natural medicines, either alone or in combination with their prescribed diabetes medications, to lower blood glucose and/or improve HbA1c.5 Some of the most commonly used products are banaba, bitter melon, fenugreek, and Gymnema (hypoglycemics), along with American or panax ginseng, cassia cinnamon, chromium, prickly pear cactus, soy, or vanadium (insulin sensitizers).

Diagnosis

Patient history aids in the clinical diagnosis of hypoglycemia and should be reviewed to determine a potential drug-induced cause. History also might identify a medication dispensing error (e.g., the onset of hypoglycemia following a recent medication refill). Hospitalists should question the patient or the patient’s family as to medication use, including over-the-counter drugs, vitamins, supplements, natural foods, and other related products.

Treatment

Glucose should be administered to maintain a plasma glucose level of at least 50 gm/dL. This may be achieved orally via frequent meals or snacks, or intravenously. The underlying cause should be addressed. In drug- or medication-induced cases, the causative agent should be removed or retitrated to an effective dose that does not cause hypoglycemia.

Upon further questioning, the patient admitted she’d been taking 3,000 mg of a bitter melon product per day. She took this in addition to all her prescribed medications. Because bitter melon has an insulin-like effect, its use in combination with glimepiride led to the clinically significant hypoglycemic reaction, which required hospitalization and treatment. Prior to discharge, the patient promised to discuss the use of alternative and natural products with her pharmacist or physician before trying anything new. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City.

References

1. Guettier JM, Gorden P. Hypoglycemia. Endocrinol Metab Clin North Am. 2006;35:753-766.
2. Holt HH. Drug-induced hypoglycemia: overview. The University of Maryland Medical Center Web site. Available at: www.umm.edu/ency/article/000310.htm. Accessed March 2, 2009.
3. Hurd R. Drug-induced hypoglycemia. Drugs.com Web site. Available at: www.drugs.com/enc/drug-induced-hypoglycemia.html. Accessed March 2, 2009.
4. Mehlhorn AJ, Brown DA. Safety concerns with fluoroquinolones. Ann Pharmacother. 2007; 41:1859-1866.
5. Natural medicines in the clinical management of diabetes. Natural Medicines Comprehensive Database Web site. Available at: www.naturaldatabase.com. Accessed March 3, 2009.
6. Teva announces approval and launch of generic Imitrex tablets. Available at: finance.yahoo.com/news/Teva-Announces-Approval-and-bw-14308223.html/print. Accessed March 2, 2009.
7. Additional strengths of Avinza available. Monthly Prescribing Reference Web site. Available at: www.empr.com/Additional-strengths-of-Avinza-available/article/126905/. Accessed March 2, 2009.
8. Gelnique treatment for overactive bladder. Drugs.com Web site. Available at: www.drugs.com/gelnique.html. Accessed March 2, 2009.
9. Reclast label. The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/cder/foi/label/2008/021817s002lbl.pdf. Accessed March 2, 2009.
10. Clopidogrel bisulfate (marketed as Plavix). The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/medwatch/safety/2009/safety09.htm#plavix. Accessed March 2, 2009.
11. PPI interactions with clopidogrel. Med Lett Drugs Ther. 2009;51 (1303):2-3.
12. PPI interactions with clopidogrel revisited. Med Lett Drugs Ther. 2009;51(1306):13-4.
13. Xigris (Drotrecogin alfa [activated]): early communication about an ongoing safety review. The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/medwatch/safety/2009/safety09.htm#Xigris. Accessed March 2, 2009.

Let’s look at a case: A known diabetic patient has been in good control, with glycosylated hemoglobin (HbA1c) levels lower than 6.5 gm/dL the past two years. Her medication regimen has remained relatively stable during that time. Her daily medications include simvastatin, 40 mg; metformin extended release, 2,000 mg; sitagliptin, 100 mg; glimepiride, 8 mg; quinapril, 20 mg; a multivitamin; calcium carbonate, 1,500 mg; and an 81-mg aspirin.

Her lipid panel, liver and renal function tests, and blood pressure are all within normal limits. However, she was admitted to the hospital with a plasma glucose level of 38 mg/dL.

Upon physical examination, she appears diaphoretic, with weakness, confusion, tremulousness, and palpitations. She is treated with glucose to maintain a level of above 50 mg/dL, and she responds without long-term sequelae.

What precipitated this event?

Drug-Induced Hypoglycemia

Hypoglycemia may represent a lab error or artifactual hypoglycemia due to glycolysis in the collection sample. To determine a pathological cause of hypoglycemia, the triad of low plasma glucose, hypoglycemia symptoms, and symptom resolution with correction of the blood glucose level should be used.1 Hypoglycemia is most often seen in diabetic patients and is the most commonly noted endocrine emergency in the inpatient setting, as well as in the ambulatory setting. Some common causes of hypoglycemia in diabetes patients include alcohol consumption, skipping meals, too much exercise, and intentional or unintentional medication overdoses.2

Treatment is required when the blood glucose level is below 45 gm/dL. Symptoms include anxiety, tremulousness, nausea, sweating, palpitation, and hunger.3 More severe symptoms related to compromised central nervous system function include weakness, fatigue, confusion, seizures, focal neurologic deficits, and coma.

The most common causes of drug-induced hypoglycemia are insulin, ethanol, or sulfonylureas. Risk factors associated with unintentional overdose of sulfonylureas include advanced age, drug-to-drug interactions, and decreased renal or hepatic clearance. Other drugs have been reported to cause hypoglycemia. Some of these include high-dose salicylates, beta-blockers, haloperidol, monoamine oxidase inhibitors, other sulfonamides (particularly trimethoprim-sulfamethoxazole), pentamidine, quinine/quinidine, and quinolone antibiotics (e.g., gatifloxacin or levofloxacin).4

Diabetics use more than 120 natural medicines, either alone or in combination with their prescribed diabetes medications, to lower blood glucose and/or improve HbA1c.5 Some of the most commonly used products are banaba, bitter melon, fenugreek, and Gymnema (hypoglycemics), along with American or panax ginseng, cassia cinnamon, chromium, prickly pear cactus, soy, or vanadium (insulin sensitizers).

Diagnosis

Patient history aids in the clinical diagnosis of hypoglycemia and should be reviewed to determine a potential drug-induced cause. History also might identify a medication dispensing error (e.g., the onset of hypoglycemia following a recent medication refill). Hospitalists should question the patient or the patient’s family as to medication use, including over-the-counter drugs, vitamins, supplements, natural foods, and other related products.

Treatment

Glucose should be administered to maintain a plasma glucose level of at least 50 gm/dL. This may be achieved orally via frequent meals or snacks, or intravenously. The underlying cause should be addressed. In drug- or medication-induced cases, the causative agent should be removed or retitrated to an effective dose that does not cause hypoglycemia.

Upon further questioning, the patient admitted she’d been taking 3,000 mg of a bitter melon product per day. She took this in addition to all her prescribed medications. Because bitter melon has an insulin-like effect, its use in combination with glimepiride led to the clinically significant hypoglycemic reaction, which required hospitalization and treatment. Prior to discharge, the patient promised to discuss the use of alternative and natural products with her pharmacist or physician before trying anything new. TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City.

References

1. Guettier JM, Gorden P. Hypoglycemia. Endocrinol Metab Clin North Am. 2006;35:753-766.
2. Holt HH. Drug-induced hypoglycemia: overview. The University of Maryland Medical Center Web site. Available at: www.umm.edu/ency/article/000310.htm. Accessed March 2, 2009.
3. Hurd R. Drug-induced hypoglycemia. Drugs.com Web site. Available at: www.drugs.com/enc/drug-induced-hypoglycemia.html. Accessed March 2, 2009.
4. Mehlhorn AJ, Brown DA. Safety concerns with fluoroquinolones. Ann Pharmacother. 2007; 41:1859-1866.
5. Natural medicines in the clinical management of diabetes. Natural Medicines Comprehensive Database Web site. Available at: www.naturaldatabase.com. Accessed March 3, 2009.
6. Teva announces approval and launch of generic Imitrex tablets. Available at: finance.yahoo.com/news/Teva-Announces-Approval-and-bw-14308223.html/print. Accessed March 2, 2009.
7. Additional strengths of Avinza available. Monthly Prescribing Reference Web site. Available at: www.empr.com/Additional-strengths-of-Avinza-available/article/126905/. Accessed March 2, 2009.
8. Gelnique treatment for overactive bladder. Drugs.com Web site. Available at: www.drugs.com/gelnique.html. Accessed March 2, 2009.
9. Reclast label. The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/cder/foi/label/2008/021817s002lbl.pdf. Accessed March 2, 2009.
10. Clopidogrel bisulfate (marketed as Plavix). The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/medwatch/safety/2009/safety09.htm#plavix. Accessed March 2, 2009.
11. PPI interactions with clopidogrel. Med Lett Drugs Ther. 2009;51 (1303):2-3.
12. PPI interactions with clopidogrel revisited. Med Lett Drugs Ther. 2009;51(1306):13-4.
13. Xigris (Drotrecogin alfa [activated]): early communication about an ongoing safety review. The U.S. Food and Drug Administration Web site. Available at: www.fda.gov/medwatch/safety/2009/safety09.htm#Xigris. Accessed March 2, 2009.

Most HM groups (HMGs) participate in quality initiatives in their hospitals, according to new SHM research. Moreover, 7 out of 10 HMGs participating in QI initiatives are leading those efforts at their hospitals.

The findings are part of SHM’s 2008-2009 Focused Survey, the latest in a series of reports commissioned by the Practice Analysis Committee. The survey and report concentrate on topics of interest from SHM’s comprehensive, biannual survey of its membership.

The survey compiled responses from 145 HMG leaders. In addition to QI initiatives, participants in the survey responded to a variety of questions, including quality-based incentives, hospitalist turnover, and the use of part-time hospitalists.

These surveys answer the kinds of questions that often come up when hospitalists and hospitals begin to evaluate their performance and plan for the future.

—Joe Miller, SHM’s executive advisor to the CEO

“This is certain to be a conversation starter for hospitalists, hospital executives, and others,” says Burke Kealey, MD, FHM, medical director for hospital medicine at St. Paul, Minn.-based HealthPartners and chair of SHM’s Practice Analysis Committee. “The Focused Survey is an opportunity for SHM to answer some of the pressing questions that healthcare executives and providers have about managing a hospitalist practice within the larger context of the hospital.”

Hospital executives and hospitalists use SHM survey findings to better understand what is going on in the specialty, says Joe Miller, SHM’s executive advisor to the CEO. “These surveys answer the kinds of questions that often come up when hospitalists and hospitals begin to evaluate their performance and plan for the future,” Miller says. “We use their questions as source material for this survey, so we can help them answer questions like, ‘How are most hospitalists participating in QI?’ or ‘How are other hospitalists using part-time staff members?’ ”

Hospitalists Lead the Way

Hospitalists continue to be at the forefront of QI initiatives within their hospitals, according to the latest survey. Almost all respondents (96.5%) reported that their HMG participated in QI programs; the average HMG has six hospitalists playing an active role in QI within the hospital.

The survey also found that 72.1% of respondents involved in QI activity reported that their hospitalists were “responsible for leading project(s)” on QI initiatives.

“The findings about the active role hospitalists play in QI initiatives may surprise even the most staunch advocate of QI within the hospital medicine specialty,” says Leslie Flores, MHA, SHM’s director of the Practice Management Institute and leader of the Focused Survey research. “In essence, it shows that nearly every hospitalist group is active in promoting QI, and that the vast majority of them are taking a leadership position to improve quality. … It is remarkable and extremely exciting that hospitalists are so deeply involved in QI in their organizations.”

The survey identified patient safety, clinical QI, and quality-related IT initiatives as most popular.

Quality Incentive Compensation

In order to track HMG quality incentive compensation, the 2008-2009 Focused Survey asked similar questions about the topic to questions in the 2006-2007 Focused Survey. Quality incentive compensation—paying bonuses or additional payments for meeting QI measures—not only increased markedly in the past two years, but a majority of HMGs also have adopted the practice. The number of HMGs that have quality incentive compensation plans has increased by 39% since 2006, according to the survey.

Nine out of 10 HMGs that receive performance-based compensation reported that the source of the compensation was the hospital or health system. In most cases, the compensation was paid to an individual hospitalist, which represents a shift from 2006, when more groups reported receiving the compensation directly.

The survey also shows that hospitals and HMGs use a number of process measures to evaluate QI incentives, including participation in quality or safety committees, transition of care measures, or core measures for heart failure, pneumonia, and acute myocardial infarction.

New Numbers Dispel High Turnover Myth

For years, the conventional wisdom throughout the healthcare community has been that HM suffers from a high turnover rate among its hospitalists. Focused Survey findings suggest otherwise. In fact, turnover rates for hospitalist groups have remained constant since 2005. Nearly a third (31.7%) of HMGs reported no turnover at all within the past 12 months.

“Getting an accurate idea about turnover in hospitalist groups has been an ongoing challenge in our research,” Flores says. “In this year’s Focused Survey, we provided clearer definitions and asked more specific questions to improve our measurement of turnover.”

The added specificity only served to reinforce findings from previous surveys that showed relatively low turnover rates. The most recent research revealed a 12.7% turnover rate, compared with 13% in 2007 and 12% in 2005.

The latest Focused Survey also includes detailed findings on turnover among full-time hospitalists compared with part-time hospitalists.

Part-Time vs. Full-Time

The new data challenge long-held assumptions about the role of part-time hospitalists. The survey queried HMGs about full-time and part-time hospitalist staff, and the proportion of time that each employee covers in the hospital.

Although there isn’t a consensus about what constitutes a full-time hospitalist, it is clear that they cover the vast majority (85%) of HMG staff hours. Part-time hospitalists are responsible for 10% of hospitalist staff hours, and “casual” hospitalists—temporary hospitalists or moonlighters—make up the remaining 5%.

Part-time hospitalists share the same responsibilities as their full-time colleagues, according to the report. More than 70% of HMG leaders said their part-time staff is deployed to cover the same shifts and responsibilities as full-time staff. Many HMGs use part-time staff to cover night and weekend shifts.

Trend Today, Initiative Tomorrow

Taken together, SHM’s bi-annual survey and Focused Survey have begun to reveal some of the most prevalent trends within the specialty, including low turnover and a specialty-wide QI emphasis. However, Flores sees room for additional research in the near future.

“There is a lot more to learn about the nature of hospitalists’ involvement in organizational quality initiatives and what benefits that involvement is delivering to their organizations,” she says. “The survey suggests some areas, particularly in the quality arena, where SHM can develop additional programs and services to support hospitalists and the work they do.”

The 10-page 2008-2009 Focused Survey report is available at www.hospitalmedicine.org/shmstore. TH

Brendon Shank is a freelance writer based in Philadelphia.

Chapter Update

Philadelphia Tri-State Area

The Philadelphia Tri-State Area chapter kicked off its 2009 meeting March 26 with its new “pharma-free” format. The chapter’s decision to forgo an expensive meal and industry-sponsored lecture was the result of an agreement to create more open dialogue among its members.

Chapter co-presidents Jen Myers, assistant professor of clinical medicine and patient safety officer at the Hospital of the University of Pennsylvania, and Erik DeLue, MD, MBA, medical director of the hospitalist program at Virtua Memorial Hospital in Mount Holly, N.J., kicked off the meeting, which focused on recruiting in a competitive market. Despite SHM’s collective recruiting challenges, most medical directors indicated that their groups were fully staffed.

Future meetings will be held at various medical institutions around the greater Philadelphia area. The next is to be held this month at Christiana Medical Center in Wilmington, Del. Future topics will be centered on pragmatic, nonclinical concerns for hospitalists, such as how to best utilize allied health providers.

Most HM groups (HMGs) participate in quality initiatives in their hospitals, according to new SHM research. Moreover, 7 out of 10 HMGs participating in QI initiatives are leading those efforts at their hospitals.

The findings are part of SHM’s 2008-2009 Focused Survey, the latest in a series of reports commissioned by the Practice Analysis Committee. The survey and report concentrate on topics of interest from SHM’s comprehensive, biannual survey of its membership.

The survey compiled responses from 145 HMG leaders. In addition to QI initiatives, participants in the survey responded to a variety of questions, including quality-based incentives, hospitalist turnover, and the use of part-time hospitalists.

These surveys answer the kinds of questions that often come up when hospitalists and hospitals begin to evaluate their performance and plan for the future.

—Joe Miller, SHM’s executive advisor to the CEO

“This is certain to be a conversation starter for hospitalists, hospital executives, and others,” says Burke Kealey, MD, FHM, medical director for hospital medicine at St. Paul, Minn.-based HealthPartners and chair of SHM’s Practice Analysis Committee. “The Focused Survey is an opportunity for SHM to answer some of the pressing questions that healthcare executives and providers have about managing a hospitalist practice within the larger context of the hospital.”

Hospital executives and hospitalists use SHM survey findings to better understand what is going on in the specialty, says Joe Miller, SHM’s executive advisor to the CEO. “These surveys answer the kinds of questions that often come up when hospitalists and hospitals begin to evaluate their performance and plan for the future,” Miller says. “We use their questions as source material for this survey, so we can help them answer questions like, ‘How are most hospitalists participating in QI?’ or ‘How are other hospitalists using part-time staff members?’ ”

Hospitalists Lead the Way

Hospitalists continue to be at the forefront of QI initiatives within their hospitals, according to the latest survey. Almost all respondents (96.5%) reported that their HMG participated in QI programs; the average HMG has six hospitalists playing an active role in QI within the hospital.

The survey also found that 72.1% of respondents involved in QI activity reported that their hospitalists were “responsible for leading project(s)” on QI initiatives.

“The findings about the active role hospitalists play in QI initiatives may surprise even the most staunch advocate of QI within the hospital medicine specialty,” says Leslie Flores, MHA, SHM’s director of the Practice Management Institute and leader of the Focused Survey research. “In essence, it shows that nearly every hospitalist group is active in promoting QI, and that the vast majority of them are taking a leadership position to improve quality. … It is remarkable and extremely exciting that hospitalists are so deeply involved in QI in their organizations.”

The survey identified patient safety, clinical QI, and quality-related IT initiatives as most popular.

Quality Incentive Compensation

In order to track HMG quality incentive compensation, the 2008-2009 Focused Survey asked similar questions about the topic to questions in the 2006-2007 Focused Survey. Quality incentive compensation—paying bonuses or additional payments for meeting QI measures—not only increased markedly in the past two years, but a majority of HMGs also have adopted the practice. The number of HMGs that have quality incentive compensation plans has increased by 39% since 2006, according to the survey.

Nine out of 10 HMGs that receive performance-based compensation reported that the source of the compensation was the hospital or health system. In most cases, the compensation was paid to an individual hospitalist, which represents a shift from 2006, when more groups reported receiving the compensation directly.

The survey also shows that hospitals and HMGs use a number of process measures to evaluate QI incentives, including participation in quality or safety committees, transition of care measures, or core measures for heart failure, pneumonia, and acute myocardial infarction.

New Numbers Dispel High Turnover Myth

For years, the conventional wisdom throughout the healthcare community has been that HM suffers from a high turnover rate among its hospitalists. Focused Survey findings suggest otherwise. In fact, turnover rates for hospitalist groups have remained constant since 2005. Nearly a third (31.7%) of HMGs reported no turnover at all within the past 12 months.

“Getting an accurate idea about turnover in hospitalist groups has been an ongoing challenge in our research,” Flores says. “In this year’s Focused Survey, we provided clearer definitions and asked more specific questions to improve our measurement of turnover.”

The added specificity only served to reinforce findings from previous surveys that showed relatively low turnover rates. The most recent research revealed a 12.7% turnover rate, compared with 13% in 2007 and 12% in 2005.

The latest Focused Survey also includes detailed findings on turnover among full-time hospitalists compared with part-time hospitalists.

Part-Time vs. Full-Time

The new data challenge long-held assumptions about the role of part-time hospitalists. The survey queried HMGs about full-time and part-time hospitalist staff, and the proportion of time that each employee covers in the hospital.

Although there isn’t a consensus about what constitutes a full-time hospitalist, it is clear that they cover the vast majority (85%) of HMG staff hours. Part-time hospitalists are responsible for 10% of hospitalist staff hours, and “casual” hospitalists—temporary hospitalists or moonlighters—make up the remaining 5%.

Part-time hospitalists share the same responsibilities as their full-time colleagues, according to the report. More than 70% of HMG leaders said their part-time staff is deployed to cover the same shifts and responsibilities as full-time staff. Many HMGs use part-time staff to cover night and weekend shifts.

Trend Today, Initiative Tomorrow

Taken together, SHM’s bi-annual survey and Focused Survey have begun to reveal some of the most prevalent trends within the specialty, including low turnover and a specialty-wide QI emphasis. However, Flores sees room for additional research in the near future.

“There is a lot more to learn about the nature of hospitalists’ involvement in organizational quality initiatives and what benefits that involvement is delivering to their organizations,” she says. “The survey suggests some areas, particularly in the quality arena, where SHM can develop additional programs and services to support hospitalists and the work they do.”

The 10-page 2008-2009 Focused Survey report is available at www.hospitalmedicine.org/shmstore. TH

Brendon Shank is a freelance writer based in Philadelphia.

Chapter Update

Philadelphia Tri-State Area

The Philadelphia Tri-State Area chapter kicked off its 2009 meeting March 26 with its new “pharma-free” format. The chapter’s decision to forgo an expensive meal and industry-sponsored lecture was the result of an agreement to create more open dialogue among its members.

Chapter co-presidents Jen Myers, assistant professor of clinical medicine and patient safety officer at the Hospital of the University of Pennsylvania, and Erik DeLue, MD, MBA, medical director of the hospitalist program at Virtua Memorial Hospital in Mount Holly, N.J., kicked off the meeting, which focused on recruiting in a competitive market. Despite SHM’s collective recruiting challenges, most medical directors indicated that their groups were fully staffed.

Future meetings will be held at various medical institutions around the greater Philadelphia area. The next is to be held this month at Christiana Medical Center in Wilmington, Del. Future topics will be centered on pragmatic, nonclinical concerns for hospitalists, such as how to best utilize allied health providers.

Most HM groups (HMGs) participate in quality initiatives in their hospitals, according to new SHM research. Moreover, 7 out of 10 HMGs participating in QI initiatives are leading those efforts at their hospitals.

The findings are part of SHM’s 2008-2009 Focused Survey, the latest in a series of reports commissioned by the Practice Analysis Committee. The survey and report concentrate on topics of interest from SHM’s comprehensive, biannual survey of its membership.

The survey compiled responses from 145 HMG leaders. In addition to QI initiatives, participants in the survey responded to a variety of questions, including quality-based incentives, hospitalist turnover, and the use of part-time hospitalists.

These surveys answer the kinds of questions that often come up when hospitalists and hospitals begin to evaluate their performance and plan for the future.

—Joe Miller, SHM’s executive advisor to the CEO

“This is certain to be a conversation starter for hospitalists, hospital executives, and others,” says Burke Kealey, MD, FHM, medical director for hospital medicine at St. Paul, Minn.-based HealthPartners and chair of SHM’s Practice Analysis Committee. “The Focused Survey is an opportunity for SHM to answer some of the pressing questions that healthcare executives and providers have about managing a hospitalist practice within the larger context of the hospital.”

Hospital executives and hospitalists use SHM survey findings to better understand what is going on in the specialty, says Joe Miller, SHM’s executive advisor to the CEO. “These surveys answer the kinds of questions that often come up when hospitalists and hospitals begin to evaluate their performance and plan for the future,” Miller says. “We use their questions as source material for this survey, so we can help them answer questions like, ‘How are most hospitalists participating in QI?’ or ‘How are other hospitalists using part-time staff members?’ ”

Hospitalists Lead the Way

Hospitalists continue to be at the forefront of QI initiatives within their hospitals, according to the latest survey. Almost all respondents (96.5%) reported that their HMG participated in QI programs; the average HMG has six hospitalists playing an active role in QI within the hospital.

The survey also found that 72.1% of respondents involved in QI activity reported that their hospitalists were “responsible for leading project(s)” on QI initiatives.

“The findings about the active role hospitalists play in QI initiatives may surprise even the most staunch advocate of QI within the hospital medicine specialty,” says Leslie Flores, MHA, SHM’s director of the Practice Management Institute and leader of the Focused Survey research. “In essence, it shows that nearly every hospitalist group is active in promoting QI, and that the vast majority of them are taking a leadership position to improve quality. … It is remarkable and extremely exciting that hospitalists are so deeply involved in QI in their organizations.”

The survey identified patient safety, clinical QI, and quality-related IT initiatives as most popular.

Quality Incentive Compensation

In order to track HMG quality incentive compensation, the 2008-2009 Focused Survey asked similar questions about the topic to questions in the 2006-2007 Focused Survey. Quality incentive compensation—paying bonuses or additional payments for meeting QI measures—not only increased markedly in the past two years, but a majority of HMGs also have adopted the practice. The number of HMGs that have quality incentive compensation plans has increased by 39% since 2006, according to the survey.

Nine out of 10 HMGs that receive performance-based compensation reported that the source of the compensation was the hospital or health system. In most cases, the compensation was paid to an individual hospitalist, which represents a shift from 2006, when more groups reported receiving the compensation directly.

The survey also shows that hospitals and HMGs use a number of process measures to evaluate QI incentives, including participation in quality or safety committees, transition of care measures, or core measures for heart failure, pneumonia, and acute myocardial infarction.

New Numbers Dispel High Turnover Myth

For years, the conventional wisdom throughout the healthcare community has been that HM suffers from a high turnover rate among its hospitalists. Focused Survey findings suggest otherwise. In fact, turnover rates for hospitalist groups have remained constant since 2005. Nearly a third (31.7%) of HMGs reported no turnover at all within the past 12 months.

“Getting an accurate idea about turnover in hospitalist groups has been an ongoing challenge in our research,” Flores says. “In this year’s Focused Survey, we provided clearer definitions and asked more specific questions to improve our measurement of turnover.”

The added specificity only served to reinforce findings from previous surveys that showed relatively low turnover rates. The most recent research revealed a 12.7% turnover rate, compared with 13% in 2007 and 12% in 2005.

The latest Focused Survey also includes detailed findings on turnover among full-time hospitalists compared with part-time hospitalists.

Part-Time vs. Full-Time

The new data challenge long-held assumptions about the role of part-time hospitalists. The survey queried HMGs about full-time and part-time hospitalist staff, and the proportion of time that each employee covers in the hospital.

Although there isn’t a consensus about what constitutes a full-time hospitalist, it is clear that they cover the vast majority (85%) of HMG staff hours. Part-time hospitalists are responsible for 10% of hospitalist staff hours, and “casual” hospitalists—temporary hospitalists or moonlighters—make up the remaining 5%.

Part-time hospitalists share the same responsibilities as their full-time colleagues, according to the report. More than 70% of HMG leaders said their part-time staff is deployed to cover the same shifts and responsibilities as full-time staff. Many HMGs use part-time staff to cover night and weekend shifts.

Trend Today, Initiative Tomorrow

Taken together, SHM’s bi-annual survey and Focused Survey have begun to reveal some of the most prevalent trends within the specialty, including low turnover and a specialty-wide QI emphasis. However, Flores sees room for additional research in the near future.

“There is a lot more to learn about the nature of hospitalists’ involvement in organizational quality initiatives and what benefits that involvement is delivering to their organizations,” she says. “The survey suggests some areas, particularly in the quality arena, where SHM can develop additional programs and services to support hospitalists and the work they do.”

The 10-page 2008-2009 Focused Survey report is available at www.hospitalmedicine.org/shmstore. TH

Brendon Shank is a freelance writer based in Philadelphia.

Chapter Update

Philadelphia Tri-State Area

The Philadelphia Tri-State Area chapter kicked off its 2009 meeting March 26 with its new “pharma-free” format. The chapter’s decision to forgo an expensive meal and industry-sponsored lecture was the result of an agreement to create more open dialogue among its members.

Chapter co-presidents Jen Myers, assistant professor of clinical medicine and patient safety officer at the Hospital of the University of Pennsylvania, and Erik DeLue, MD, MBA, medical director of the hospitalist program at Virtua Memorial Hospital in Mount Holly, N.J., kicked off the meeting, which focused on recruiting in a competitive market. Despite SHM’s collective recruiting challenges, most medical directors indicated that their groups were fully staffed.

Future meetings will be held at various medical institutions around the greater Philadelphia area. The next is to be held this month at Christiana Medical Center in Wilmington, Del. Future topics will be centered on pragmatic, nonclinical concerns for hospitalists, such as how to best utilize allied health providers.

Case

A 45-year-old female with a history of cellulitis requiring peripheral inserted central catheter (PICC) line placement for intravenous antibiotics presents two weeks after line removal with persistent, dull, aching pain in her right shoulder and difficulty removing the rings on her right hand. The pain worsens with exercise and is relieved with rest. The physical exam reveals nonpitting edema of her hand. The ultrasound shows subclavian vein thrombosis. What is the best approach to treating her upper extremity deep venous thrombosis (UEDVT)?

Background

DVT and pulmonary embolism (PE) have been subject to increased publicity recently, and both conditions are recognized as serious entities with life-threatening consequences. In fact, more people die annually from blood clots than breast cancer and AIDS combined.1,2 Still, the increased DVT and PE awareness is primarily focused on lower extremity DVT (LEDVT)), while UEDVT is thought of as a more benign entity. However, current data suggest that UEDVT is associated with equally significant morbidity and mortality.

UEDVT prevalence has increased in step with the increased use of central venous catheters (CVCs) and pacemakers. Although most patients present with pain, swelling, parathesias, and prominent veins throughout the arm or shoulder, many patients will not display any local DVT symptoms. For example, Kabani et al recently presented data for 1,275 patients admitted to the surgical ICU over a 12-month period. They found the incidence of UEDVT was higher than that of LEDVT (17% vs. 11%; P=0.11). They also determined that scanning all four extremities diagnosed more DVT than two-extremity scans (33% vs. 7%; P<0.001).3

While current medical literature has pushed for increased UEDVT attention, there is no consensus on its treatment. Recent American College of Chest Physicians (ACCP) guidelines addressed UEDVT treatment specifically and recommended analogous treatment to LEDVT with heparin and warfarin.4 This follows prospective studies that have shown patients with UEDVT and LEDVT have similar three-month clinical outcomes. The ACCP guidelines do not specifically recommend different treatment courses based on whether the UEDVT is catheter-related or not. Furthermore, while one might assume that removal of an associated catheter might reduce the treatment duration, there is limited data to support shorter courses in this scenario.

Review of the Data

Incidence: UEDVT is becoming more common secondary to increased interventions in the upper extremity (CVC, pacemaker), and is more easily recognized due to improvement in noninvasive ultrasound technology. UEDVT accounts for up to 10% of all DVT, with an incidence of approximately three per 100,000 persons in the general population.5-8 Because UEDVT can also be asymptomatic, it is believed that the incidence likely is higher than previously reported, but prospective data are lacking.

Risk factors: UEDVT is further categorized as either primary or secondary, depending upon the cause. First described in the late 1800s, spontaneous primary thrombosis of the upper extremity, or Paget-Schroetter syndrome, accounts for approximately 20% of UEDVT.9 Primary UEDVT includes both idiopathic and “effort-related” thrombosis. Effort-related thrombosis usually develops among young people after strenuous or repetitive exercise, such as pitching a baseball. Some hypothesize that effort-related thrombosis is related to a hypercoaguable state or anatomic abnormalities, although a specific cause, such as thoracic outlet syndrome, is found in only 5% of these cases.10,11

Secondary UEDVT characterizes thrombosis in which an endogenous or exogenous risk factor is present. Endogenous risk factors include coagulation abnormalities, such as antithrombin, protein C and protein S deficiencies; factor V Leiden gene mutation; hyperhomocysteinemia; and antiphospholipid antibody syndrome. Exogenous risk factors include CVC pacemakers, intracardiac defibrillators, malignancy, previous or concurrent LEDVT, oral contraceptives, some artificial reproductive technologies (women can develop ovarian hyperstimulation syndrome, which is associated with increased hypercoaguability), trauma, and IV drug use (especially cocaine).5,12-14

Clinical presentation and diagnosis: Swelling (80% of patients) and pain (40% of patients) are the most common UEDVT symptoms at presentation.2 Other clinical features include new, prominent veins throughout the shoulder girdle, erythema, increased warmth, functional impairment, parathesias, and non-specific feelings of arm heaviness or discomfort. Symptoms typically worsen with arm use and improve with rest and elevation.15 Patients with UEDVT related to CVC are more likely to be asymptomatic and may present only with PE.16 The differential diagnosis includes superficial phlebitis, lymphatic edema, hematoma, contusions, venous compression, and muscle tears.17

Contrast venography is the gold standard for the UEDVT diagnosis. However, it is more expensive and invasive than ultrasound, and thus serial compression ultrasound is now the standard test in UEDVT evaluation. Then again, contrast venography remains the test of choice in patients with high pre-test probability and negative ultrasound results.18,19

Prevention: Nearly 70% of secondary UEDVT is associated with a CVC.5 Further, CVC use is the most powerful predictor of UEDVT (adjusted odds ratio (OR), 9.7; 95% CI, 7.8 to 12.2).2 Despite the association between CVCs and UEDVT, anticoagulant prophylaxis is not recommended. Studies evaluating the results of 1-mg warfarin conflict and include small populations. Warfarin’s potential interaction with antibiotics and dosing variance based on nutritional intake logically prompted studies on the potential benefit of low-weight molecular heparain (LWMH); however, these studies have failed to show benefit.20,21

Treatment: Recent ACCP guidelines recommend treating UEDVT patients with unfractionated heparin (UFH) or LMWH and warfarin, with an INR goal of 2 to 3 for at least three months depending upon the overall clinical scenario. Two small studies evaluating catheter-related thrombosis (15 patients in each trial) reported no subsequent embolic phenomenon.22,23 Some authors interpreted this data to mean UEDVT was not as morbid as LEDVT and, subsequently, that catheter-related UEDVTs require only one month of therapy. Since the small studies were published, the increasing incidence and relevance of UEDVT have become more widely recognized, and most authors are recommending three months of treatment.

Still, it’s important to note that there aren’t any published data directly comparing the one-month and the three-month anticoagulation therapies. The RIETE registry, which is the largest ongoing published registry of patients with confirmed DVT or PE, reports similar three-month clinical outcomes between those with UEDVT and LEDVT.

Small, single-center trials have shown that active intervention, such as thrombolysis, surgery, or multi-staged approaches are associated with increased vein patency and decreased rates of post-thrombotic syndrome.24,25 However, ACCP has withheld general recommendations for these interventions based on a lack of sufficient data to comment on their overall safety and efficacy, as well as comparable rates of post-thrombotic syndrome (15% to 50%) in studies that directly compared surgical and medical intervention. In fact, the ACCP recommends against interventional treatments unless the patient has failed anticoagulation therapy, has severe symptoms, and expertise is available.4

Superior vena cava filters are available at some centers for patients in whom anticoagulation is contraindicated, but efficacy data is limited. While the data for filter use in UEDVT is limited, its use should be considered in patients who have a contraindication to anticoagulation and remain high risk for UEDVT (e.g., prolonged central line placement).

Complications: Post-thrombotic syndrome (PTS) is the most significant local complication of UEDVT. PTS characteristics are edema, pain, venous ulcers, and skin pigmentation changes, and it is the result of chronic venous insufficiency due to the clot. A meta-analysis of clinical studies on UEDVT noted that PTS occurs in 7% to 46% (mean 15%) of patients.26 One hypothesis for the wide range in frequency is the lack of clear diagnostic criteria for PTS.27 No clear beneficial treatment or prevention for PTS exists, but many recommend graduated compression stockings for the arm.

Residual and recurrent thrombosis are associated with increased PTS risk, which emphasizes the need for further study of interventional treatment because preliminary work has shown increased rates of vein patency in comparison to anticoagulants alone. Recurrent venous thromboembolism (VTE), another local complication, appears to occur less often than it does in patients with LEDVTs, but reaches 8% after five years of followup.28

PE is less common on presentation among patients with UEDVT when compared to patients with LEDVT, but when PE occurs, the three-month outcome is similar.3 PE appears to be more frequent in patients who have a CVC, with an incidence as high as 36% of DVT patients.4,13,21,29

Increased mortality: The mortality among UEDVT patients has been described as 10% to 50% in the 12 months after diagnosis, which is much higher than the ratio in LEDVT patients.21,30 This in part is due to sicker cohorts getting UEDVT. For example, patients with distant metastasis are more likely to develop UEDVT than those with confined malignancy (adjusted OR 11.5; 95% CI, 1.6 to 80.2).31

Occult malignancy, most commonly lung cancer or lymphoma, has been found in as many as 24% of UEDVT patients.32 The high rate of mortality associated with UEDVT appears to be related more with the patient's overall poor clinical condition rather than directly related to complications from the DVT. However, its presence should alert hospitalists to the patient's potentially poorer prognosis and prompt evaluation for occult malignancy if no risk factor is present.

Back to the Case

This patient should be started on either UFH or LMWH while simultaneously beginning warfarin. She should continue warfarin treatment for at least three months, with a goal INR of 2.0 to 3.0, similar to treatment for LEDVT. The ultimate treatment duration with warfarin follows the same guidelines as treatment with a LEDVT. Although prophylaxis is not routinely recommended, dosing 1 mg of warfarin beginning three days before subsequent CVC placement should be considered if this patient requires a future CVC. Additionally, an evaluation for occult malignancy should be considered in this patient.

Bottom Line

Upper extremity DVT is not a benign condition, and is associated with a general increase in mortality. It should be treated similarly to LEDVT in order to decrease PTS, recurrent DVT, and PE. TH

Dr. Hollberg is a clinical instructor in the section of hospital medicine at Emory University Hospital in Atlanta.

References

1. Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on Thrombosis, American Heart Association. Circulation. 1996;93(12):2212-2245.
2. Gerotziafas GT, Samama MM. Prophylaxis of venous thromboembolism in medical patients. Curr Opin Pulm Med. 2004;10(5):356-365.
3. Kabani L, et al. Upper extremity DVT as prevalent as lower extremity DVT in ICU patients. Society of Critical Care Medicine (SCCM) 38th annual Critical Care Congress: Abstract 305. Presented Feb. 2, 2009.
4. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6Suppl):454S-545S.
5. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ. Upper extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation. 2004;110:1605.
6. Munoz FJ, Mismetti P, Poggio R, et al. Clinical outcome of patients with an upper-extremity deep vein thrombosis: results from the RIETE registry. Chest. 2008,133:143-148.
7. Coon WW, Willis PW. Thrombosis of axillary and subclavian veins. Arch Surg. 1967;94(5):657-663.
8. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity—a report of a series and review of the literature. Surgery. 1988;104(3):561-567.
9. Bernardi E, Piccioli A, Marchiori A, Girolami B, Prandoni P. Upper extremity deep vein thrombosis: risk factors, diagnosis, and management. Semin Vasc Med. 2001;1(1):105;110.
10. Heron E, Lozinguez O, Alhenc-Gelas M, Emmerich J, Flessinger JN. Hypercoagulable states in primary upper-extremity deep vein thrombosis. Arch Intern Med. 2000;160:382-386.
11. Ninet J, Demolombe-Rague S, Bureau Du Colombier P, Coppere B. Les thromboses veineuses profondes des members superieurs. Sang Thromb Vaisseaux. 1994;6:103-114.
12. Painter TD, Kerpf M. Deep venous thrombosis of the upper extremity five years experience at a university hospital. Angiology. 1984;35(35):743-749.
13. Chan WS, Ginsberg JS. A review of upper extremity deep vein thrombosis in pregnancy: unmasking the “ART” behind the clot. J Thromb Haemost. 2006;4(8):1673-1677.
14. Hughes MJ, D’Agostino JC. Upper extremity deep vein thrombosis: a case report and review of current diagnostic/therapeutic modalities. Am J Emerg Med. 1994;12(6):631-635.
15. Prandoni P, Polistena P, Bernardi E, et al. Upper extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med. 1997;157:57-62.
16. Van Rooden CJ, Tesslar ME, Osanto S, Rosendal FR, Huisman MV. Deep vein thrombosis associated with central venous catheters—a review. J Thromb Haemost. 2005;3:2049-2419.
17. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity—report of a series and review of the literature. Surgery. 1988;104(3):561-567.
18. Bernardi E, Pesavento R, Prandoni P. Upper extremity deep venous thrombosis. Semin Thromb Hemost. 2006;32(7):729-736.
19. Baxter GM, McKechnie S, Duffy P. Colour Doppler ultrasound in deep venous thrombosis: a comparison with venography. Clin Radiol. 1990;42(1):32-36.
20. Bern MM, Lokich JJ, Wallach SR, et al. Very low doses of warfarin can prevent thrombosis in central venous catheters. A randomized prospective trial. Ann Intern Med. 1990;112(6):423-428.
21. Couban S, Goodyear M, Burnell M, et al. Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol. 2005;23(18):4063-4069.
22. Lokich JJ, Both A, Benotti P. Complications and management of implanted central venous catheters. J Clin Oncol. 1985;3:710-717.
23. Moss JF, Wagman LD, Rijhmaki DU, Terz JJ. Central venous thrombosis related to the silastic Hickman-Broviac catheter in an oncologic population. J Parenter Enteral Nutr. 1989;13:397.
24. Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous thrombosis of the axillary-subclavian vein. J Vasc Surg. 1993;17:305-315.
25. Malcynski J, O’Donnell TF, Mackey WC. Long-term results of treatment for axillary subclavian vein thrombosis. Can J Surg. 1993;36:365-371.
26. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep vein thrombosis in adults: a systematic review. Thromb Res. 2006;117(6):609-614.
27. Baarslag HJ, Koopman MM, Hutten BA, et al. Long-term follow up of patients with suspected deep vein thrombosis of the upper extremity: survival, risk factors and post-thrombotic syndrome. Eur J Intern Med. 2004;15:503-507.
28. Prandoni P, Bernardi E, Marchiori A, et al. The long term clinical consequence of acute deep venous thrombosis of the arm: prospective cohort study. BMJ. 2004;329:484-485.
29. Monreal M, Raventos A, Lerma R, et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines—a prospective study. Thromb Haemost. 1994;72(4):548-550.
30. Hingorani A, Ascher E, Lorenson E, et al. Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population. J Vasc Surg. 1997;26:853-860.
31. Blom JW, Doggen CM, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep vein thrombosis. J Thromb Haemost. 2005;3:2471-2478.
32. Girolami A, Prandoni P, Zanon E, Bagatella P, Girolami B. Venous thromboses of upper limbs are more frequently associated with occult cancer as compared with those of lower limbs. Blood Coagul Fibrinolysis. 1999;10(8):455-457.

Case

A 45-year-old female with a history of cellulitis requiring peripheral inserted central catheter (PICC) line placement for intravenous antibiotics presents two weeks after line removal with persistent, dull, aching pain in her right shoulder and difficulty removing the rings on her right hand. The pain worsens with exercise and is relieved with rest. The physical exam reveals nonpitting edema of her hand. The ultrasound shows subclavian vein thrombosis. What is the best approach to treating her upper extremity deep venous thrombosis (UEDVT)?

Background

DVT and pulmonary embolism (PE) have been subject to increased publicity recently, and both conditions are recognized as serious entities with life-threatening consequences. In fact, more people die annually from blood clots than breast cancer and AIDS combined.1,2 Still, the increased DVT and PE awareness is primarily focused on lower extremity DVT (LEDVT)), while UEDVT is thought of as a more benign entity. However, current data suggest that UEDVT is associated with equally significant morbidity and mortality.

UEDVT prevalence has increased in step with the increased use of central venous catheters (CVCs) and pacemakers. Although most patients present with pain, swelling, parathesias, and prominent veins throughout the arm or shoulder, many patients will not display any local DVT symptoms. For example, Kabani et al recently presented data for 1,275 patients admitted to the surgical ICU over a 12-month period. They found the incidence of UEDVT was higher than that of LEDVT (17% vs. 11%; P=0.11). They also determined that scanning all four extremities diagnosed more DVT than two-extremity scans (33% vs. 7%; P<0.001).3

While current medical literature has pushed for increased UEDVT attention, there is no consensus on its treatment. Recent American College of Chest Physicians (ACCP) guidelines addressed UEDVT treatment specifically and recommended analogous treatment to LEDVT with heparin and warfarin.4 This follows prospective studies that have shown patients with UEDVT and LEDVT have similar three-month clinical outcomes. The ACCP guidelines do not specifically recommend different treatment courses based on whether the UEDVT is catheter-related or not. Furthermore, while one might assume that removal of an associated catheter might reduce the treatment duration, there is limited data to support shorter courses in this scenario.

Review of the Data

Incidence: UEDVT is becoming more common secondary to increased interventions in the upper extremity (CVC, pacemaker), and is more easily recognized due to improvement in noninvasive ultrasound technology. UEDVT accounts for up to 10% of all DVT, with an incidence of approximately three per 100,000 persons in the general population.5-8 Because UEDVT can also be asymptomatic, it is believed that the incidence likely is higher than previously reported, but prospective data are lacking.

Risk factors: UEDVT is further categorized as either primary or secondary, depending upon the cause. First described in the late 1800s, spontaneous primary thrombosis of the upper extremity, or Paget-Schroetter syndrome, accounts for approximately 20% of UEDVT.9 Primary UEDVT includes both idiopathic and “effort-related” thrombosis. Effort-related thrombosis usually develops among young people after strenuous or repetitive exercise, such as pitching a baseball. Some hypothesize that effort-related thrombosis is related to a hypercoaguable state or anatomic abnormalities, although a specific cause, such as thoracic outlet syndrome, is found in only 5% of these cases.10,11

Secondary UEDVT characterizes thrombosis in which an endogenous or exogenous risk factor is present. Endogenous risk factors include coagulation abnormalities, such as antithrombin, protein C and protein S deficiencies; factor V Leiden gene mutation; hyperhomocysteinemia; and antiphospholipid antibody syndrome. Exogenous risk factors include CVC pacemakers, intracardiac defibrillators, malignancy, previous or concurrent LEDVT, oral contraceptives, some artificial reproductive technologies (women can develop ovarian hyperstimulation syndrome, which is associated with increased hypercoaguability), trauma, and IV drug use (especially cocaine).5,12-14

Clinical presentation and diagnosis: Swelling (80% of patients) and pain (40% of patients) are the most common UEDVT symptoms at presentation.2 Other clinical features include new, prominent veins throughout the shoulder girdle, erythema, increased warmth, functional impairment, parathesias, and non-specific feelings of arm heaviness or discomfort. Symptoms typically worsen with arm use and improve with rest and elevation.15 Patients with UEDVT related to CVC are more likely to be asymptomatic and may present only with PE.16 The differential diagnosis includes superficial phlebitis, lymphatic edema, hematoma, contusions, venous compression, and muscle tears.17

Contrast venography is the gold standard for the UEDVT diagnosis. However, it is more expensive and invasive than ultrasound, and thus serial compression ultrasound is now the standard test in UEDVT evaluation. Then again, contrast venography remains the test of choice in patients with high pre-test probability and negative ultrasound results.18,19

Prevention: Nearly 70% of secondary UEDVT is associated with a CVC.5 Further, CVC use is the most powerful predictor of UEDVT (adjusted odds ratio (OR), 9.7; 95% CI, 7.8 to 12.2).2 Despite the association between CVCs and UEDVT, anticoagulant prophylaxis is not recommended. Studies evaluating the results of 1-mg warfarin conflict and include small populations. Warfarin’s potential interaction with antibiotics and dosing variance based on nutritional intake logically prompted studies on the potential benefit of low-weight molecular heparain (LWMH); however, these studies have failed to show benefit.20,21

Treatment: Recent ACCP guidelines recommend treating UEDVT patients with unfractionated heparin (UFH) or LMWH and warfarin, with an INR goal of 2 to 3 for at least three months depending upon the overall clinical scenario. Two small studies evaluating catheter-related thrombosis (15 patients in each trial) reported no subsequent embolic phenomenon.22,23 Some authors interpreted this data to mean UEDVT was not as morbid as LEDVT and, subsequently, that catheter-related UEDVTs require only one month of therapy. Since the small studies were published, the increasing incidence and relevance of UEDVT have become more widely recognized, and most authors are recommending three months of treatment.

Still, it’s important to note that there aren’t any published data directly comparing the one-month and the three-month anticoagulation therapies. The RIETE registry, which is the largest ongoing published registry of patients with confirmed DVT or PE, reports similar three-month clinical outcomes between those with UEDVT and LEDVT.

Small, single-center trials have shown that active intervention, such as thrombolysis, surgery, or multi-staged approaches are associated with increased vein patency and decreased rates of post-thrombotic syndrome.24,25 However, ACCP has withheld general recommendations for these interventions based on a lack of sufficient data to comment on their overall safety and efficacy, as well as comparable rates of post-thrombotic syndrome (15% to 50%) in studies that directly compared surgical and medical intervention. In fact, the ACCP recommends against interventional treatments unless the patient has failed anticoagulation therapy, has severe symptoms, and expertise is available.4

Superior vena cava filters are available at some centers for patients in whom anticoagulation is contraindicated, but efficacy data is limited. While the data for filter use in UEDVT is limited, its use should be considered in patients who have a contraindication to anticoagulation and remain high risk for UEDVT (e.g., prolonged central line placement).

Complications: Post-thrombotic syndrome (PTS) is the most significant local complication of UEDVT. PTS characteristics are edema, pain, venous ulcers, and skin pigmentation changes, and it is the result of chronic venous insufficiency due to the clot. A meta-analysis of clinical studies on UEDVT noted that PTS occurs in 7% to 46% (mean 15%) of patients.26 One hypothesis for the wide range in frequency is the lack of clear diagnostic criteria for PTS.27 No clear beneficial treatment or prevention for PTS exists, but many recommend graduated compression stockings for the arm.

Residual and recurrent thrombosis are associated with increased PTS risk, which emphasizes the need for further study of interventional treatment because preliminary work has shown increased rates of vein patency in comparison to anticoagulants alone. Recurrent venous thromboembolism (VTE), another local complication, appears to occur less often than it does in patients with LEDVTs, but reaches 8% after five years of followup.28

PE is less common on presentation among patients with UEDVT when compared to patients with LEDVT, but when PE occurs, the three-month outcome is similar.3 PE appears to be more frequent in patients who have a CVC, with an incidence as high as 36% of DVT patients.4,13,21,29

Increased mortality: The mortality among UEDVT patients has been described as 10% to 50% in the 12 months after diagnosis, which is much higher than the ratio in LEDVT patients.21,30 This in part is due to sicker cohorts getting UEDVT. For example, patients with distant metastasis are more likely to develop UEDVT than those with confined malignancy (adjusted OR 11.5; 95% CI, 1.6 to 80.2).31

Occult malignancy, most commonly lung cancer or lymphoma, has been found in as many as 24% of UEDVT patients.32 The high rate of mortality associated with UEDVT appears to be related more with the patient's overall poor clinical condition rather than directly related to complications from the DVT. However, its presence should alert hospitalists to the patient's potentially poorer prognosis and prompt evaluation for occult malignancy if no risk factor is present.

Back to the Case

This patient should be started on either UFH or LMWH while simultaneously beginning warfarin. She should continue warfarin treatment for at least three months, with a goal INR of 2.0 to 3.0, similar to treatment for LEDVT. The ultimate treatment duration with warfarin follows the same guidelines as treatment with a LEDVT. Although prophylaxis is not routinely recommended, dosing 1 mg of warfarin beginning three days before subsequent CVC placement should be considered if this patient requires a future CVC. Additionally, an evaluation for occult malignancy should be considered in this patient.

Bottom Line

Upper extremity DVT is not a benign condition, and is associated with a general increase in mortality. It should be treated similarly to LEDVT in order to decrease PTS, recurrent DVT, and PE. TH

Dr. Hollberg is a clinical instructor in the section of hospital medicine at Emory University Hospital in Atlanta.

References

1. Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on Thrombosis, American Heart Association. Circulation. 1996;93(12):2212-2245.
2. Gerotziafas GT, Samama MM. Prophylaxis of venous thromboembolism in medical patients. Curr Opin Pulm Med. 2004;10(5):356-365.
3. Kabani L, et al. Upper extremity DVT as prevalent as lower extremity DVT in ICU patients. Society of Critical Care Medicine (SCCM) 38th annual Critical Care Congress: Abstract 305. Presented Feb. 2, 2009.
4. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6Suppl):454S-545S.
5. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ. Upper extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation. 2004;110:1605.
6. Munoz FJ, Mismetti P, Poggio R, et al. Clinical outcome of patients with an upper-extremity deep vein thrombosis: results from the RIETE registry. Chest. 2008,133:143-148.
7. Coon WW, Willis PW. Thrombosis of axillary and subclavian veins. Arch Surg. 1967;94(5):657-663.
8. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity—a report of a series and review of the literature. Surgery. 1988;104(3):561-567.
9. Bernardi E, Piccioli A, Marchiori A, Girolami B, Prandoni P. Upper extremity deep vein thrombosis: risk factors, diagnosis, and management. Semin Vasc Med. 2001;1(1):105;110.
10. Heron E, Lozinguez O, Alhenc-Gelas M, Emmerich J, Flessinger JN. Hypercoagulable states in primary upper-extremity deep vein thrombosis. Arch Intern Med. 2000;160:382-386.
11. Ninet J, Demolombe-Rague S, Bureau Du Colombier P, Coppere B. Les thromboses veineuses profondes des members superieurs. Sang Thromb Vaisseaux. 1994;6:103-114.
12. Painter TD, Kerpf M. Deep venous thrombosis of the upper extremity five years experience at a university hospital. Angiology. 1984;35(35):743-749.
13. Chan WS, Ginsberg JS. A review of upper extremity deep vein thrombosis in pregnancy: unmasking the “ART” behind the clot. J Thromb Haemost. 2006;4(8):1673-1677.
14. Hughes MJ, D’Agostino JC. Upper extremity deep vein thrombosis: a case report and review of current diagnostic/therapeutic modalities. Am J Emerg Med. 1994;12(6):631-635.
15. Prandoni P, Polistena P, Bernardi E, et al. Upper extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med. 1997;157:57-62.
16. Van Rooden CJ, Tesslar ME, Osanto S, Rosendal FR, Huisman MV. Deep vein thrombosis associated with central venous catheters—a review. J Thromb Haemost. 2005;3:2049-2419.
17. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity—report of a series and review of the literature. Surgery. 1988;104(3):561-567.
18. Bernardi E, Pesavento R, Prandoni P. Upper extremity deep venous thrombosis. Semin Thromb Hemost. 2006;32(7):729-736.
19. Baxter GM, McKechnie S, Duffy P. Colour Doppler ultrasound in deep venous thrombosis: a comparison with venography. Clin Radiol. 1990;42(1):32-36.
20. Bern MM, Lokich JJ, Wallach SR, et al. Very low doses of warfarin can prevent thrombosis in central venous catheters. A randomized prospective trial. Ann Intern Med. 1990;112(6):423-428.
21. Couban S, Goodyear M, Burnell M, et al. Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol. 2005;23(18):4063-4069.
22. Lokich JJ, Both A, Benotti P. Complications and management of implanted central venous catheters. J Clin Oncol. 1985;3:710-717.
23. Moss JF, Wagman LD, Rijhmaki DU, Terz JJ. Central venous thrombosis related to the silastic Hickman-Broviac catheter in an oncologic population. J Parenter Enteral Nutr. 1989;13:397.
24. Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous thrombosis of the axillary-subclavian vein. J Vasc Surg. 1993;17:305-315.
25. Malcynski J, O’Donnell TF, Mackey WC. Long-term results of treatment for axillary subclavian vein thrombosis. Can J Surg. 1993;36:365-371.
26. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep vein thrombosis in adults: a systematic review. Thromb Res. 2006;117(6):609-614.
27. Baarslag HJ, Koopman MM, Hutten BA, et al. Long-term follow up of patients with suspected deep vein thrombosis of the upper extremity: survival, risk factors and post-thrombotic syndrome. Eur J Intern Med. 2004;15:503-507.
28. Prandoni P, Bernardi E, Marchiori A, et al. The long term clinical consequence of acute deep venous thrombosis of the arm: prospective cohort study. BMJ. 2004;329:484-485.
29. Monreal M, Raventos A, Lerma R, et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines—a prospective study. Thromb Haemost. 1994;72(4):548-550.
30. Hingorani A, Ascher E, Lorenson E, et al. Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population. J Vasc Surg. 1997;26:853-860.
31. Blom JW, Doggen CM, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep vein thrombosis. J Thromb Haemost. 2005;3:2471-2478.
32. Girolami A, Prandoni P, Zanon E, Bagatella P, Girolami B. Venous thromboses of upper limbs are more frequently associated with occult cancer as compared with those of lower limbs. Blood Coagul Fibrinolysis. 1999;10(8):455-457.

Case

A 45-year-old female with a history of cellulitis requiring peripheral inserted central catheter (PICC) line placement for intravenous antibiotics presents two weeks after line removal with persistent, dull, aching pain in her right shoulder and difficulty removing the rings on her right hand. The pain worsens with exercise and is relieved with rest. The physical exam reveals nonpitting edema of her hand. The ultrasound shows subclavian vein thrombosis. What is the best approach to treating her upper extremity deep venous thrombosis (UEDVT)?

Background

DVT and pulmonary embolism (PE) have been subject to increased publicity recently, and both conditions are recognized as serious entities with life-threatening consequences. In fact, more people die annually from blood clots than breast cancer and AIDS combined.1,2 Still, the increased DVT and PE awareness is primarily focused on lower extremity DVT (LEDVT)), while UEDVT is thought of as a more benign entity. However, current data suggest that UEDVT is associated with equally significant morbidity and mortality.

UEDVT prevalence has increased in step with the increased use of central venous catheters (CVCs) and pacemakers. Although most patients present with pain, swelling, parathesias, and prominent veins throughout the arm or shoulder, many patients will not display any local DVT symptoms. For example, Kabani et al recently presented data for 1,275 patients admitted to the surgical ICU over a 12-month period. They found the incidence of UEDVT was higher than that of LEDVT (17% vs. 11%; P=0.11). They also determined that scanning all four extremities diagnosed more DVT than two-extremity scans (33% vs. 7%; P<0.001).3

While current medical literature has pushed for increased UEDVT attention, there is no consensus on its treatment. Recent American College of Chest Physicians (ACCP) guidelines addressed UEDVT treatment specifically and recommended analogous treatment to LEDVT with heparin and warfarin.4 This follows prospective studies that have shown patients with UEDVT and LEDVT have similar three-month clinical outcomes. The ACCP guidelines do not specifically recommend different treatment courses based on whether the UEDVT is catheter-related or not. Furthermore, while one might assume that removal of an associated catheter might reduce the treatment duration, there is limited data to support shorter courses in this scenario.

Review of the Data

Incidence: UEDVT is becoming more common secondary to increased interventions in the upper extremity (CVC, pacemaker), and is more easily recognized due to improvement in noninvasive ultrasound technology. UEDVT accounts for up to 10% of all DVT, with an incidence of approximately three per 100,000 persons in the general population.5-8 Because UEDVT can also be asymptomatic, it is believed that the incidence likely is higher than previously reported, but prospective data are lacking.

Risk factors: UEDVT is further categorized as either primary or secondary, depending upon the cause. First described in the late 1800s, spontaneous primary thrombosis of the upper extremity, or Paget-Schroetter syndrome, accounts for approximately 20% of UEDVT.9 Primary UEDVT includes both idiopathic and “effort-related” thrombosis. Effort-related thrombosis usually develops among young people after strenuous or repetitive exercise, such as pitching a baseball. Some hypothesize that effort-related thrombosis is related to a hypercoaguable state or anatomic abnormalities, although a specific cause, such as thoracic outlet syndrome, is found in only 5% of these cases.10,11

Secondary UEDVT characterizes thrombosis in which an endogenous or exogenous risk factor is present. Endogenous risk factors include coagulation abnormalities, such as antithrombin, protein C and protein S deficiencies; factor V Leiden gene mutation; hyperhomocysteinemia; and antiphospholipid antibody syndrome. Exogenous risk factors include CVC pacemakers, intracardiac defibrillators, malignancy, previous or concurrent LEDVT, oral contraceptives, some artificial reproductive technologies (women can develop ovarian hyperstimulation syndrome, which is associated with increased hypercoaguability), trauma, and IV drug use (especially cocaine).5,12-14

Clinical presentation and diagnosis: Swelling (80% of patients) and pain (40% of patients) are the most common UEDVT symptoms at presentation.2 Other clinical features include new, prominent veins throughout the shoulder girdle, erythema, increased warmth, functional impairment, parathesias, and non-specific feelings of arm heaviness or discomfort. Symptoms typically worsen with arm use and improve with rest and elevation.15 Patients with UEDVT related to CVC are more likely to be asymptomatic and may present only with PE.16 The differential diagnosis includes superficial phlebitis, lymphatic edema, hematoma, contusions, venous compression, and muscle tears.17

Contrast venography is the gold standard for the UEDVT diagnosis. However, it is more expensive and invasive than ultrasound, and thus serial compression ultrasound is now the standard test in UEDVT evaluation. Then again, contrast venography remains the test of choice in patients with high pre-test probability and negative ultrasound results.18,19

Prevention: Nearly 70% of secondary UEDVT is associated with a CVC.5 Further, CVC use is the most powerful predictor of UEDVT (adjusted odds ratio (OR), 9.7; 95% CI, 7.8 to 12.2).2 Despite the association between CVCs and UEDVT, anticoagulant prophylaxis is not recommended. Studies evaluating the results of 1-mg warfarin conflict and include small populations. Warfarin’s potential interaction with antibiotics and dosing variance based on nutritional intake logically prompted studies on the potential benefit of low-weight molecular heparain (LWMH); however, these studies have failed to show benefit.20,21

Treatment: Recent ACCP guidelines recommend treating UEDVT patients with unfractionated heparin (UFH) or LMWH and warfarin, with an INR goal of 2 to 3 for at least three months depending upon the overall clinical scenario. Two small studies evaluating catheter-related thrombosis (15 patients in each trial) reported no subsequent embolic phenomenon.22,23 Some authors interpreted this data to mean UEDVT was not as morbid as LEDVT and, subsequently, that catheter-related UEDVTs require only one month of therapy. Since the small studies were published, the increasing incidence and relevance of UEDVT have become more widely recognized, and most authors are recommending three months of treatment.

Still, it’s important to note that there aren’t any published data directly comparing the one-month and the three-month anticoagulation therapies. The RIETE registry, which is the largest ongoing published registry of patients with confirmed DVT or PE, reports similar three-month clinical outcomes between those with UEDVT and LEDVT.

Small, single-center trials have shown that active intervention, such as thrombolysis, surgery, or multi-staged approaches are associated with increased vein patency and decreased rates of post-thrombotic syndrome.24,25 However, ACCP has withheld general recommendations for these interventions based on a lack of sufficient data to comment on their overall safety and efficacy, as well as comparable rates of post-thrombotic syndrome (15% to 50%) in studies that directly compared surgical and medical intervention. In fact, the ACCP recommends against interventional treatments unless the patient has failed anticoagulation therapy, has severe symptoms, and expertise is available.4

Superior vena cava filters are available at some centers for patients in whom anticoagulation is contraindicated, but efficacy data is limited. While the data for filter use in UEDVT is limited, its use should be considered in patients who have a contraindication to anticoagulation and remain high risk for UEDVT (e.g., prolonged central line placement).

Complications: Post-thrombotic syndrome (PTS) is the most significant local complication of UEDVT. PTS characteristics are edema, pain, venous ulcers, and skin pigmentation changes, and it is the result of chronic venous insufficiency due to the clot. A meta-analysis of clinical studies on UEDVT noted that PTS occurs in 7% to 46% (mean 15%) of patients.26 One hypothesis for the wide range in frequency is the lack of clear diagnostic criteria for PTS.27 No clear beneficial treatment or prevention for PTS exists, but many recommend graduated compression stockings for the arm.

Residual and recurrent thrombosis are associated with increased PTS risk, which emphasizes the need for further study of interventional treatment because preliminary work has shown increased rates of vein patency in comparison to anticoagulants alone. Recurrent venous thromboembolism (VTE), another local complication, appears to occur less often than it does in patients with LEDVTs, but reaches 8% after five years of followup.28

PE is less common on presentation among patients with UEDVT when compared to patients with LEDVT, but when PE occurs, the three-month outcome is similar.3 PE appears to be more frequent in patients who have a CVC, with an incidence as high as 36% of DVT patients.4,13,21,29

Increased mortality: The mortality among UEDVT patients has been described as 10% to 50% in the 12 months after diagnosis, which is much higher than the ratio in LEDVT patients.21,30 This in part is due to sicker cohorts getting UEDVT. For example, patients with distant metastasis are more likely to develop UEDVT than those with confined malignancy (adjusted OR 11.5; 95% CI, 1.6 to 80.2).31

Occult malignancy, most commonly lung cancer or lymphoma, has been found in as many as 24% of UEDVT patients.32 The high rate of mortality associated with UEDVT appears to be related more with the patient's overall poor clinical condition rather than directly related to complications from the DVT. However, its presence should alert hospitalists to the patient's potentially poorer prognosis and prompt evaluation for occult malignancy if no risk factor is present.

Back to the Case

This patient should be started on either UFH or LMWH while simultaneously beginning warfarin. She should continue warfarin treatment for at least three months, with a goal INR of 2.0 to 3.0, similar to treatment for LEDVT. The ultimate treatment duration with warfarin follows the same guidelines as treatment with a LEDVT. Although prophylaxis is not routinely recommended, dosing 1 mg of warfarin beginning three days before subsequent CVC placement should be considered if this patient requires a future CVC. Additionally, an evaluation for occult malignancy should be considered in this patient.

Bottom Line

Upper extremity DVT is not a benign condition, and is associated with a general increase in mortality. It should be treated similarly to LEDVT in order to decrease PTS, recurrent DVT, and PE. TH

Dr. Hollberg is a clinical instructor in the section of hospital medicine at Emory University Hospital in Atlanta.

References

1. Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Council on Thrombosis, American Heart Association. Circulation. 1996;93(12):2212-2245.
2. Gerotziafas GT, Samama MM. Prophylaxis of venous thromboembolism in medical patients. Curr Opin Pulm Med. 2004;10(5):356-365.
3. Kabani L, et al. Upper extremity DVT as prevalent as lower extremity DVT in ICU patients. Society of Critical Care Medicine (SCCM) 38th annual Critical Care Congress: Abstract 305. Presented Feb. 2, 2009.
4. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ. Therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6Suppl):454S-545S.
5. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ. Upper extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation. 2004;110:1605.
6. Munoz FJ, Mismetti P, Poggio R, et al. Clinical outcome of patients with an upper-extremity deep vein thrombosis: results from the RIETE registry. Chest. 2008,133:143-148.
7. Coon WW, Willis PW. Thrombosis of axillary and subclavian veins. Arch Surg. 1967;94(5):657-663.
8. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity—a report of a series and review of the literature. Surgery. 1988;104(3):561-567.
9. Bernardi E, Piccioli A, Marchiori A, Girolami B, Prandoni P. Upper extremity deep vein thrombosis: risk factors, diagnosis, and management. Semin Vasc Med. 2001;1(1):105;110.
10. Heron E, Lozinguez O, Alhenc-Gelas M, Emmerich J, Flessinger JN. Hypercoagulable states in primary upper-extremity deep vein thrombosis. Arch Intern Med. 2000;160:382-386.
11. Ninet J, Demolombe-Rague S, Bureau Du Colombier P, Coppere B. Les thromboses veineuses profondes des members superieurs. Sang Thromb Vaisseaux. 1994;6:103-114.
12. Painter TD, Kerpf M. Deep venous thrombosis of the upper extremity five years experience at a university hospital. Angiology. 1984;35(35):743-749.
13. Chan WS, Ginsberg JS. A review of upper extremity deep vein thrombosis in pregnancy: unmasking the “ART” behind the clot. J Thromb Haemost. 2006;4(8):1673-1677.
14. Hughes MJ, D’Agostino JC. Upper extremity deep vein thrombosis: a case report and review of current diagnostic/therapeutic modalities. Am J Emerg Med. 1994;12(6):631-635.
15. Prandoni P, Polistena P, Bernardi E, et al. Upper extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med. 1997;157:57-62.
16. Van Rooden CJ, Tesslar ME, Osanto S, Rosendal FR, Huisman MV. Deep vein thrombosis associated with central venous catheters—a review. J Thromb Haemost. 2005;3:2049-2419.
17. Horattas MC, Wright DJ, Fenton AH, et al. Changing concepts of deep venous thrombosis of the upper extremity—report of a series and review of the literature. Surgery. 1988;104(3):561-567.
18. Bernardi E, Pesavento R, Prandoni P. Upper extremity deep venous thrombosis. Semin Thromb Hemost. 2006;32(7):729-736.
19. Baxter GM, McKechnie S, Duffy P. Colour Doppler ultrasound in deep venous thrombosis: a comparison with venography. Clin Radiol. 1990;42(1):32-36.
20. Bern MM, Lokich JJ, Wallach SR, et al. Very low doses of warfarin can prevent thrombosis in central venous catheters. A randomized prospective trial. Ann Intern Med. 1990;112(6):423-428.
21. Couban S, Goodyear M, Burnell M, et al. Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol. 2005;23(18):4063-4069.
22. Lokich JJ, Both A, Benotti P. Complications and management of implanted central venous catheters. J Clin Oncol. 1985;3:710-717.
23. Moss JF, Wagman LD, Rijhmaki DU, Terz JJ. Central venous thrombosis related to the silastic Hickman-Broviac catheter in an oncologic population. J Parenter Enteral Nutr. 1989;13:397.
24. Machleder HI. Evaluation of a new treatment strategy for Paget-Schroetter syndrome: spontaneous thrombosis of the axillary-subclavian vein. J Vasc Surg. 1993;17:305-315.
25. Malcynski J, O’Donnell TF, Mackey WC. Long-term results of treatment for axillary subclavian vein thrombosis. Can J Surg. 1993;36:365-371.
26. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep vein thrombosis in adults: a systematic review. Thromb Res. 2006;117(6):609-614.
27. Baarslag HJ, Koopman MM, Hutten BA, et al. Long-term follow up of patients with suspected deep vein thrombosis of the upper extremity: survival, risk factors and post-thrombotic syndrome. Eur J Intern Med. 2004;15:503-507.
28. Prandoni P, Bernardi E, Marchiori A, et al. The long term clinical consequence of acute deep venous thrombosis of the arm: prospective cohort study. BMJ. 2004;329:484-485.
29. Monreal M, Raventos A, Lerma R, et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines—a prospective study. Thromb Haemost. 1994;72(4):548-550.
30. Hingorani A, Ascher E, Lorenson E, et al. Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population. J Vasc Surg. 1997;26:853-860.
31. Blom JW, Doggen CM, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep vein thrombosis. J Thromb Haemost. 2005;3:2471-2478.
32. Girolami A, Prandoni P, Zanon E, Bagatella P, Girolami B. Venous thromboses of upper limbs are more frequently associated with occult cancer as compared with those of lower limbs. Blood Coagul Fibrinolysis. 1999;10(8):455-457.

William Ford, MD, FHM, was just three years removed from residency when he assumed his first HM leadership role. His qualifications were impressive, but because he was just in his early 30s, his soon-to-be bosses needed some convincing that he was right for the job.

But Dr. Ford—now medical director at Cogent Healthcare and director of the HM program at Temple University in Philadelphia—quickly proved that ability, attitude, and work ethic mean as much as, if not more than, a lengthy résumé. “I don’t think you need a title to lead or a position to lead,” Dr. Ford says. “You need the will to lead.”

Q: You spent a little more than a year in private practice before you became a hospitalist. What motivated you to make the switch?

A: I really enjoy the mix of responsibilities. There’s a lot more to HM than just treating the patient. You’re actually treating the hospital. And, ultimately, it’s more fast-paced. I like the ability to be on the cutting edge of medicine, and just being in a hospital keeps you on your toes from a medical perspective.

Q: Your first two clinical sites—Lehigh Valley Hospital in Allentown, Pa., and Union Hospital in Elkton, Md.—are more suburban settings. What made Temple the right fit?

A: I trained at Drexel University (also in Philadelphia), and I wanted to get back to the urban setting. I find that environment to be very challenging.

Q: How so?

A: The biggest challenge is the socioeconomic problems. Eighty percent of our patients are on Medicare or Medicaid. … In a nutshell, the challenge comes down to basic access to care.

Q: How frustrating is that for you?

A: It’s very frustrating, and it angers me. If I write a prescription for a patient, there’s a good chance the person won’t take it. If I tell them they need follow-up treatment, there’s a good chance they won’t get it. It’s not that they don’t want to. Maybe they can’t afford the co-pay, or maybe, if they haven’t been monitored by a primary-care physician (PCP), they can’t get an appointment for three months. I know we, as a group, can care for patients much better if they would follow up with our instructions. But because of the hoops they have to go through, whether for economic reasons or access reasons, many of them are coming back to the ED.

Q: What keeps you going in spite of those challenges?

A: The patients. They are a very grateful population. They know they are underserved, and they are appreciative of the care.

Q: Temple partnered with Cogent Healthcare in 2006 to manage its hospitalist program. Were you excited about being able to put your stamp on a program and really help it develop?

A: That was enormously appealing. If you’re a true leader, you’re never satisfied with the way your boss is running the program. If you really have the qualities to lead a group, you always think you can do better. … I was intrigued by the opportunity to start a group in a major teaching center that, for the first time, was outsourcing its hospitalist program and trying to solidify its teaching mission.

Q: How quickly has the program grown?

A: We’ve grown from four physicians to 27, and we treat about 15,000 inpatients annually.

Q: What advice would you give to the director of a program experiencing similar growth?

A: Be very stringent on the doctors you choose. For a lot of groups, retention/recruitment is the No. 1, No. 2, and No. 3 problem. We’ve been fortunate we haven’t made many bad hires. But the time and effort it takes to get rid of a bad hire can really end up bogging you down. I’d rather have everyone pull up their bootstraps and work a bit harder and take an extra few months to find the right person than go ahead with a bad hire simply to have another body.

Q: Were there other keys behind the program’s success?

A: There are several. I owe a great deal of the success of the program to the great doctors I work with. I received tremendous support from the department of internal medicine when I arrived, and that ensured a smooth transition. Another big component is good communication.

Q: What role has communication played?

A: Hospitals are very siloed. One group doesn’t speak to another. We’re taught to stick our head in the sand, fix the problem, and move on to the next problem. That gets you crucified in the world of HM. As hospitalists, we have to be the glue that brings all these silos together. In our profession, to be a good leader, you don’t have to be the smartest or best clinician. But you do have to have the attributes of communication and teambuilding. The key is to meet people and talk to them. Try to get to know every key hospital administrator. Don’t just write an order and go away; talk to the nurse. If you forge relationships and try to get the group more fully implemented, it will be more likely to reach its full potential.

Q: At 35, you are slightly younger than the average U.S. hospitalist, yet you’re nearly three years into your first true leadership role. Has your age ever been an issue?

A: Initially, it was a hindrance. It took four months for Temple to interview me. The biggest negative they gave to Cogent was, “He’s so young.” In any other field, 35 would not be considered a child. We’d be in the workforce for 13 years, and we’d be considered middle or senior management. Medicine in general is steeped in, “If you don’t have gray hair, you’re not able to sit at the table.” In our specialty, you can. … It doesn’t have to hinder you, but you have to be willing and able to do the right things. If you are, you will be noticed.

Q: You consider HM program marketing and branding one of your specialties. Why are those efforts necessary?

A: If you don’t market yourself, you’ll die, particularly in a competitive market. Whether you are at an academic center or a small community hospital or even a larger hospital, you could have two or three hospitalist groups all vying for the same patient volume. You need to give yourself a differential advantage.

Q: How do you do that?

A: You have to get out and meet people and shake some hands. You have to meet all of your customers, and you have to find out if they are happy or displeased. You have to communicate with them. You have to think about your customers, and they’re not just the patients in the bed. Your customers also are your administration, your PCPs, your subspecialists. … It’s no different than a vendor selling fax machines. We are a business, and if doctors don’t think that, they’re very naive.

Q: You’re also a big proponent of team-building within groups.

A: Definitely. That’s the foundation. Groups are going to coalesce differently. In my group at Lehigh Valley, we all had a Fourth of July party. We were never so close as after that one experience when we shared dinner together. It may be as simple as that. At Temple, I had all 25 of us meet and go over a teambuilding exercise to understand what values people have and why they come to work. I asked them to tell me something I didn’t know about them. I heard everything from “I changed my name when I was 5” to “I played basketball in college.”

You’re more willing to cover for a colleague if he or she is sick if you get to know them on a personal level. And if that happens, you’re less likely to leave, and that decreases turnover. On top of everything else, you become a group. You see group buy-in and goal recognition, and you start to see those goals attained.

Q: On top of your administrative duties and teaching responsibilities, you’re still doing 10 clinical shifts per month. Why?

A: It’s hugely important for two reasons. No. 1 is respect among members of your team. No. 2 is knowledge of your service. It’s not until you get your hands dirty that you can really understand what physicians in your group are going through and figure out ways to make life better. And at the end of the day, we’re all still physicians. TH

Mark Leiser is a freelance writer in New Jersey.

William Ford, MD, FHM, was just three years removed from residency when he assumed his first HM leadership role. His qualifications were impressive, but because he was just in his early 30s, his soon-to-be bosses needed some convincing that he was right for the job.

But Dr. Ford—now medical director at Cogent Healthcare and director of the HM program at Temple University in Philadelphia—quickly proved that ability, attitude, and work ethic mean as much as, if not more than, a lengthy résumé. “I don’t think you need a title to lead or a position to lead,” Dr. Ford says. “You need the will to lead.”

Q: You spent a little more than a year in private practice before you became a hospitalist. What motivated you to make the switch?

A: I really enjoy the mix of responsibilities. There’s a lot more to HM than just treating the patient. You’re actually treating the hospital. And, ultimately, it’s more fast-paced. I like the ability to be on the cutting edge of medicine, and just being in a hospital keeps you on your toes from a medical perspective.

Q: Your first two clinical sites—Lehigh Valley Hospital in Allentown, Pa., and Union Hospital in Elkton, Md.—are more suburban settings. What made Temple the right fit?

A: I trained at Drexel University (also in Philadelphia), and I wanted to get back to the urban setting. I find that environment to be very challenging.

Q: How so?

A: The biggest challenge is the socioeconomic problems. Eighty percent of our patients are on Medicare or Medicaid. … In a nutshell, the challenge comes down to basic access to care.

Q: How frustrating is that for you?

A: It’s very frustrating, and it angers me. If I write a prescription for a patient, there’s a good chance the person won’t take it. If I tell them they need follow-up treatment, there’s a good chance they won’t get it. It’s not that they don’t want to. Maybe they can’t afford the co-pay, or maybe, if they haven’t been monitored by a primary-care physician (PCP), they can’t get an appointment for three months. I know we, as a group, can care for patients much better if they would follow up with our instructions. But because of the hoops they have to go through, whether for economic reasons or access reasons, many of them are coming back to the ED.

Q: What keeps you going in spite of those challenges?

A: The patients. They are a very grateful population. They know they are underserved, and they are appreciative of the care.

Q: Temple partnered with Cogent Healthcare in 2006 to manage its hospitalist program. Were you excited about being able to put your stamp on a program and really help it develop?

A: That was enormously appealing. If you’re a true leader, you’re never satisfied with the way your boss is running the program. If you really have the qualities to lead a group, you always think you can do better. … I was intrigued by the opportunity to start a group in a major teaching center that, for the first time, was outsourcing its hospitalist program and trying to solidify its teaching mission.

Q: How quickly has the program grown?

A: We’ve grown from four physicians to 27, and we treat about 15,000 inpatients annually.

Q: What advice would you give to the director of a program experiencing similar growth?

A: Be very stringent on the doctors you choose. For a lot of groups, retention/recruitment is the No. 1, No. 2, and No. 3 problem. We’ve been fortunate we haven’t made many bad hires. But the time and effort it takes to get rid of a bad hire can really end up bogging you down. I’d rather have everyone pull up their bootstraps and work a bit harder and take an extra few months to find the right person than go ahead with a bad hire simply to have another body.

Q: Were there other keys behind the program’s success?

A: There are several. I owe a great deal of the success of the program to the great doctors I work with. I received tremendous support from the department of internal medicine when I arrived, and that ensured a smooth transition. Another big component is good communication.

Q: What role has communication played?

A: Hospitals are very siloed. One group doesn’t speak to another. We’re taught to stick our head in the sand, fix the problem, and move on to the next problem. That gets you crucified in the world of HM. As hospitalists, we have to be the glue that brings all these silos together. In our profession, to be a good leader, you don’t have to be the smartest or best clinician. But you do have to have the attributes of communication and teambuilding. The key is to meet people and talk to them. Try to get to know every key hospital administrator. Don’t just write an order and go away; talk to the nurse. If you forge relationships and try to get the group more fully implemented, it will be more likely to reach its full potential.

Q: At 35, you are slightly younger than the average U.S. hospitalist, yet you’re nearly three years into your first true leadership role. Has your age ever been an issue?

A: Initially, it was a hindrance. It took four months for Temple to interview me. The biggest negative they gave to Cogent was, “He’s so young.” In any other field, 35 would not be considered a child. We’d be in the workforce for 13 years, and we’d be considered middle or senior management. Medicine in general is steeped in, “If you don’t have gray hair, you’re not able to sit at the table.” In our specialty, you can. … It doesn’t have to hinder you, but you have to be willing and able to do the right things. If you are, you will be noticed.

Q: You consider HM program marketing and branding one of your specialties. Why are those efforts necessary?

A: If you don’t market yourself, you’ll die, particularly in a competitive market. Whether you are at an academic center or a small community hospital or even a larger hospital, you could have two or three hospitalist groups all vying for the same patient volume. You need to give yourself a differential advantage.

Q: How do you do that?

A: You have to get out and meet people and shake some hands. You have to meet all of your customers, and you have to find out if they are happy or displeased. You have to communicate with them. You have to think about your customers, and they’re not just the patients in the bed. Your customers also are your administration, your PCPs, your subspecialists. … It’s no different than a vendor selling fax machines. We are a business, and if doctors don’t think that, they’re very naive.

Q: You’re also a big proponent of team-building within groups.

A: Definitely. That’s the foundation. Groups are going to coalesce differently. In my group at Lehigh Valley, we all had a Fourth of July party. We were never so close as after that one experience when we shared dinner together. It may be as simple as that. At Temple, I had all 25 of us meet and go over a teambuilding exercise to understand what values people have and why they come to work. I asked them to tell me something I didn’t know about them. I heard everything from “I changed my name when I was 5” to “I played basketball in college.”

You’re more willing to cover for a colleague if he or she is sick if you get to know them on a personal level. And if that happens, you’re less likely to leave, and that decreases turnover. On top of everything else, you become a group. You see group buy-in and goal recognition, and you start to see those goals attained.

Q: On top of your administrative duties and teaching responsibilities, you’re still doing 10 clinical shifts per month. Why?

A: It’s hugely important for two reasons. No. 1 is respect among members of your team. No. 2 is knowledge of your service. It’s not until you get your hands dirty that you can really understand what physicians in your group are going through and figure out ways to make life better. And at the end of the day, we’re all still physicians. TH

Mark Leiser is a freelance writer in New Jersey.

William Ford, MD, FHM, was just three years removed from residency when he assumed his first HM leadership role. His qualifications were impressive, but because he was just in his early 30s, his soon-to-be bosses needed some convincing that he was right for the job.

But Dr. Ford—now medical director at Cogent Healthcare and director of the HM program at Temple University in Philadelphia—quickly proved that ability, attitude, and work ethic mean as much as, if not more than, a lengthy résumé. “I don’t think you need a title to lead or a position to lead,” Dr. Ford says. “You need the will to lead.”

Q: You spent a little more than a year in private practice before you became a hospitalist. What motivated you to make the switch?

A: I really enjoy the mix of responsibilities. There’s a lot more to HM than just treating the patient. You’re actually treating the hospital. And, ultimately, it’s more fast-paced. I like the ability to be on the cutting edge of medicine, and just being in a hospital keeps you on your toes from a medical perspective.

Q: Your first two clinical sites—Lehigh Valley Hospital in Allentown, Pa., and Union Hospital in Elkton, Md.—are more suburban settings. What made Temple the right fit?

A: I trained at Drexel University (also in Philadelphia), and I wanted to get back to the urban setting. I find that environment to be very challenging.

Q: How so?

A: The biggest challenge is the socioeconomic problems. Eighty percent of our patients are on Medicare or Medicaid. … In a nutshell, the challenge comes down to basic access to care.

Q: How frustrating is that for you?

A: It’s very frustrating, and it angers me. If I write a prescription for a patient, there’s a good chance the person won’t take it. If I tell them they need follow-up treatment, there’s a good chance they won’t get it. It’s not that they don’t want to. Maybe they can’t afford the co-pay, or maybe, if they haven’t been monitored by a primary-care physician (PCP), they can’t get an appointment for three months. I know we, as a group, can care for patients much better if they would follow up with our instructions. But because of the hoops they have to go through, whether for economic reasons or access reasons, many of them are coming back to the ED.

Q: What keeps you going in spite of those challenges?

A: The patients. They are a very grateful population. They know they are underserved, and they are appreciative of the care.

Q: Temple partnered with Cogent Healthcare in 2006 to manage its hospitalist program. Were you excited about being able to put your stamp on a program and really help it develop?

A: That was enormously appealing. If you’re a true leader, you’re never satisfied with the way your boss is running the program. If you really have the qualities to lead a group, you always think you can do better. … I was intrigued by the opportunity to start a group in a major teaching center that, for the first time, was outsourcing its hospitalist program and trying to solidify its teaching mission.

Q: How quickly has the program grown?

A: We’ve grown from four physicians to 27, and we treat about 15,000 inpatients annually.

Q: What advice would you give to the director of a program experiencing similar growth?

A: Be very stringent on the doctors you choose. For a lot of groups, retention/recruitment is the No. 1, No. 2, and No. 3 problem. We’ve been fortunate we haven’t made many bad hires. But the time and effort it takes to get rid of a bad hire can really end up bogging you down. I’d rather have everyone pull up their bootstraps and work a bit harder and take an extra few months to find the right person than go ahead with a bad hire simply to have another body.

Q: Were there other keys behind the program’s success?

A: There are several. I owe a great deal of the success of the program to the great doctors I work with. I received tremendous support from the department of internal medicine when I arrived, and that ensured a smooth transition. Another big component is good communication.

Q: What role has communication played?

A: Hospitals are very siloed. One group doesn’t speak to another. We’re taught to stick our head in the sand, fix the problem, and move on to the next problem. That gets you crucified in the world of HM. As hospitalists, we have to be the glue that brings all these silos together. In our profession, to be a good leader, you don’t have to be the smartest or best clinician. But you do have to have the attributes of communication and teambuilding. The key is to meet people and talk to them. Try to get to know every key hospital administrator. Don’t just write an order and go away; talk to the nurse. If you forge relationships and try to get the group more fully implemented, it will be more likely to reach its full potential.

Q: At 35, you are slightly younger than the average U.S. hospitalist, yet you’re nearly three years into your first true leadership role. Has your age ever been an issue?

A: Initially, it was a hindrance. It took four months for Temple to interview me. The biggest negative they gave to Cogent was, “He’s so young.” In any other field, 35 would not be considered a child. We’d be in the workforce for 13 years, and we’d be considered middle or senior management. Medicine in general is steeped in, “If you don’t have gray hair, you’re not able to sit at the table.” In our specialty, you can. … It doesn’t have to hinder you, but you have to be willing and able to do the right things. If you are, you will be noticed.

Q: You consider HM program marketing and branding one of your specialties. Why are those efforts necessary?

A: If you don’t market yourself, you’ll die, particularly in a competitive market. Whether you are at an academic center or a small community hospital or even a larger hospital, you could have two or three hospitalist groups all vying for the same patient volume. You need to give yourself a differential advantage.

Q: How do you do that?

A: You have to get out and meet people and shake some hands. You have to meet all of your customers, and you have to find out if they are happy or displeased. You have to communicate with them. You have to think about your customers, and they’re not just the patients in the bed. Your customers also are your administration, your PCPs, your subspecialists. … It’s no different than a vendor selling fax machines. We are a business, and if doctors don’t think that, they’re very naive.

Q: You’re also a big proponent of team-building within groups.

A: Definitely. That’s the foundation. Groups are going to coalesce differently. In my group at Lehigh Valley, we all had a Fourth of July party. We were never so close as after that one experience when we shared dinner together. It may be as simple as that. At Temple, I had all 25 of us meet and go over a teambuilding exercise to understand what values people have and why they come to work. I asked them to tell me something I didn’t know about them. I heard everything from “I changed my name when I was 5” to “I played basketball in college.”

You’re more willing to cover for a colleague if he or she is sick if you get to know them on a personal level. And if that happens, you’re less likely to leave, and that decreases turnover. On top of everything else, you become a group. You see group buy-in and goal recognition, and you start to see those goals attained.

Q: On top of your administrative duties and teaching responsibilities, you’re still doing 10 clinical shifts per month. Why?

A: It’s hugely important for two reasons. No. 1 is respect among members of your team. No. 2 is knowledge of your service. It’s not until you get your hands dirty that you can really understand what physicians in your group are going through and figure out ways to make life better. And at the end of the day, we’re all still physicians. TH

Mark Leiser is a freelance writer in New Jersey.

Editors’ note: Hospitalists face difficult decisions every day, including situations that don’t always have clear-cut answers. Beginning with this month’s “HM Debate,” The Hospitalist stares down the tough questions and presents all sides of the issues. This month’s question: You are discharging a patient after treatment for a non-ST segment myocardial infarction (NSTEMI). The cardiology team recommends nonemergent coronary artery bypass grafting (CABG) for the patient’s three-vessel disease. You set up a referral for surgery, but you know the CABG morbidity and mortality rates are higher at your hospital than at a hospital 30 miles away. Should you disclose this information to your patient?

PRO

If you would tell your relative, you should tell your patient

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina and a member of SHM’s Ethics Committee.

If a patient at your hospital needs surgery or another invasive intervention, are you obligated to inform them of your hospital’s record with that procedure—particularly if the record is not as good as the one of the hospital down the street? Should loyalty to your hospital trump the risk to the patient?

In our scenario, the patient is being referred for elective surgery, and it is known that the cardiovascular team at a neighboring hospital has a better record for this procedure. It is the hospitalist’s job to present this information to the patient so that an intelligent and informed decision can be made. If the hospitalist believes the outcomes data, then an obligation exists to share that information with the patient.

If the data are subtle, one might argue that confusing the patient with more levels of decision-making is unnecessary. On the other hand, if data on performance outcomes between two institutions are clear, it presents an ethical position.

Let us assume the hospitalist is aware of poor outcomes in coronary bypass surgery at their hospital. Perhaps the mortality rates were unusually high and the hospitalist knew external consultants were brought in to identify the problems. Would you refer your patient for bypass surgery in that situation? A better question might be: Would you let a family member undergo coronary artery bypass grafting (CABG) in your hospital? Probably not. So if you would inform a family member, shouldn’t you tell your patient?

A situation like this occurred in September 2005 at the University of Massachusetts Medical Center in Worcester. Media coverage was intense, and statistics showed that thoracic surgery mortality at UMass was the highest in the state two years running. The service at the hospital was closed temporarily.1 Extensive reorganization, adoption of QI protocols, and development of oversight committees resulted in much-improved patient outcomes when the program reopened a few weeks later.

The higher-than-expected complication rate had persisted at UMass for four years before the closure and reorganization. One wonders if hospitalists and cardiologists suspected a problem with surgical outcomes before the hospital was thrust into the national spotlight. Is it our job to know our hospital’s track record in surgery and invasive procedures? Yes, it probably is. This is why a hospital’s quality-assurance committee is so important. As keeper of the outcomes data, the committee is charged with sounding an alarm when a problem is brewing.

Tech-savvy patients have access to detailed reporting on performance measures for hospitals and physicians. Interpretation of the data can be complex. High surgical complication rates might be the result of a higher-than-expected patient acuity mix—patients who were older and sicker than usual—and may not represent a system or surgeon problem. Hospitalists need to guide patients through the interpretation of this data.

Patients trust their physicians. They trust that hospitalists will provide the best advice and make recommendations with their interests at heart. To not do so violates the public trust in physicians as patient advocates. Required by law, transparency of hospital quality data is the basis of a truthful relationship between the healthcare system and the public.

HM’s reputation will be tarnished if patients perceive that the physicians are more interested in the well-being of the hospital than the well-being of the patients.

Reference

1. Kowalczyk L, Smith S. Hospital halts heart surgeries due to deaths. Boston Globe Web site. Available at: www.boston.com/news/local/articles/2005/09/22/hospital_halts_heart_surgeries_due_to_deaths. Accessed March 31, 2009.

CON

Outcome disclosure is impractical, unnecessary

Dr. Egan is a hospitalist at the University of Colorado Denver and chair of SHM’s Ethics Committee.

At first glance, disclosing information about better outcomes at another hospital seems reasonable—even ethically obligatory. However, there are several competing interests, and in the end, the existing precedent for requiring reasonable disclosure in informed consent makes more sense.

The first issue is practicality. How much is a hospitalist obligated to know, and what degree of difference must be disclosed? In the case example, the hospitalist knows better outcomes are available at a nearby facility. However, if a duty to disclose this information exists, it can’t be limited to the information that an individual hospitalist has available to them. If such a duty exists, there is a corresponding burden on providers to have consistent and accurate information to disclose. If disclosure of differing outcomes is the ethical standard, then the reasonable disclosure needs to meet some uniform criteria for when a differing outcome rises to the level that the disclosure is compelled.

Data exist for pneumonia outcomes, readmission rates, and medication errors, as well as data for physicians relative to their colleagues. The fact that a hospitalist might have incidental knowledge of differing outcomes is not sufficient to create an ethical obligation, but there must be some uniformity to a disclosure requirement.

It is easy to envision a hospitalist spending as much time disclosing outcomes data as disclosing medical information and prognosis in the process of obtaining informed consent. Hospitalists can’t be expected to manage all of that information, much less make a meaningful disclosure. Physicians’ information-management skills should focus on medical knowledge—not outcomes data.

The test case has more implications for the professionalism of the hospitalist. Ultimately, they should act in the best interest of the patient. The recommended course of treatment should maximize benefit and minimize harm. Enough information should be provided that the patient can participate in weighing risks and benefits. The hospitalist needs to decide if it is unsafe to perform the procedure at their institution, and if so, the patient should be referred out. If there is a small but real benefit to having the procedure done elsewhere, the hospitalist cannot be responsible for determining what threshold of incremental benefit warrants disclosure. Existing ethical responsibilities to protect the patient and act in their best interests already addresses the issues of disparate outcomes more effectively than a blanket disclosure policy. Patients need to trust their hospitalists, and we need to be worthy of that trust.

Mandating disclosure of better outcomes would create a conflict of interest for physicians and hospitals. This conflict would be difficult to manage. Large referral centers exist because physicians recognize their own limits and act in patients’ best interests. Requiring a new level of disclosure would mean that many hospitals (save for an elite few) would recommend patients go elsewhere a substantial part of the time.

Conflicts of interest usually are managed more than eliminated, and the current management of the tension between caring for a patient personally and referring them out based on a perception of the patient’s need for a higher level of care achieves a reasonable and balanced result. Disrupting this result with a mandated level of disclosure will result in disruption of a functional process.

Measured disclosure of relevant information is a good thing. A high level of communication and shared decision-making between physicians and patients is a good thing. Discussion of disparate outcomes may be an ethically important part of a treatment plan, but saying it is advisable in all cases is unnecessary, unmanageable, and inadvisable.

The opinions expressed herein are those of the authors and do not represent those of the Society of Hospital Medicine or The Hospitalist.

Editors’ note: Hospitalists face difficult decisions every day, including situations that don’t always have clear-cut answers. Beginning with this month’s “HM Debate,” The Hospitalist stares down the tough questions and presents all sides of the issues. This month’s question: You are discharging a patient after treatment for a non-ST segment myocardial infarction (NSTEMI). The cardiology team recommends nonemergent coronary artery bypass grafting (CABG) for the patient’s three-vessel disease. You set up a referral for surgery, but you know the CABG morbidity and mortality rates are higher at your hospital than at a hospital 30 miles away. Should you disclose this information to your patient?

PRO

If you would tell your relative, you should tell your patient

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina and a member of SHM’s Ethics Committee.

If a patient at your hospital needs surgery or another invasive intervention, are you obligated to inform them of your hospital’s record with that procedure—particularly if the record is not as good as the one of the hospital down the street? Should loyalty to your hospital trump the risk to the patient?

In our scenario, the patient is being referred for elective surgery, and it is known that the cardiovascular team at a neighboring hospital has a better record for this procedure. It is the hospitalist’s job to present this information to the patient so that an intelligent and informed decision can be made. If the hospitalist believes the outcomes data, then an obligation exists to share that information with the patient.

If the data are subtle, one might argue that confusing the patient with more levels of decision-making is unnecessary. On the other hand, if data on performance outcomes between two institutions are clear, it presents an ethical position.

Let us assume the hospitalist is aware of poor outcomes in coronary bypass surgery at their hospital. Perhaps the mortality rates were unusually high and the hospitalist knew external consultants were brought in to identify the problems. Would you refer your patient for bypass surgery in that situation? A better question might be: Would you let a family member undergo coronary artery bypass grafting (CABG) in your hospital? Probably not. So if you would inform a family member, shouldn’t you tell your patient?

A situation like this occurred in September 2005 at the University of Massachusetts Medical Center in Worcester. Media coverage was intense, and statistics showed that thoracic surgery mortality at UMass was the highest in the state two years running. The service at the hospital was closed temporarily.1 Extensive reorganization, adoption of QI protocols, and development of oversight committees resulted in much-improved patient outcomes when the program reopened a few weeks later.

The higher-than-expected complication rate had persisted at UMass for four years before the closure and reorganization. One wonders if hospitalists and cardiologists suspected a problem with surgical outcomes before the hospital was thrust into the national spotlight. Is it our job to know our hospital’s track record in surgery and invasive procedures? Yes, it probably is. This is why a hospital’s quality-assurance committee is so important. As keeper of the outcomes data, the committee is charged with sounding an alarm when a problem is brewing.

Tech-savvy patients have access to detailed reporting on performance measures for hospitals and physicians. Interpretation of the data can be complex. High surgical complication rates might be the result of a higher-than-expected patient acuity mix—patients who were older and sicker than usual—and may not represent a system or surgeon problem. Hospitalists need to guide patients through the interpretation of this data.

Patients trust their physicians. They trust that hospitalists will provide the best advice and make recommendations with their interests at heart. To not do so violates the public trust in physicians as patient advocates. Required by law, transparency of hospital quality data is the basis of a truthful relationship between the healthcare system and the public.

HM’s reputation will be tarnished if patients perceive that the physicians are more interested in the well-being of the hospital than the well-being of the patients.

Reference

1. Kowalczyk L, Smith S. Hospital halts heart surgeries due to deaths. Boston Globe Web site. Available at: www.boston.com/news/local/articles/2005/09/22/hospital_halts_heart_surgeries_due_to_deaths. Accessed March 31, 2009.

CON

Outcome disclosure is impractical, unnecessary

Dr. Egan is a hospitalist at the University of Colorado Denver and chair of SHM’s Ethics Committee.

At first glance, disclosing information about better outcomes at another hospital seems reasonable—even ethically obligatory. However, there are several competing interests, and in the end, the existing precedent for requiring reasonable disclosure in informed consent makes more sense.

The first issue is practicality. How much is a hospitalist obligated to know, and what degree of difference must be disclosed? In the case example, the hospitalist knows better outcomes are available at a nearby facility. However, if a duty to disclose this information exists, it can’t be limited to the information that an individual hospitalist has available to them. If such a duty exists, there is a corresponding burden on providers to have consistent and accurate information to disclose. If disclosure of differing outcomes is the ethical standard, then the reasonable disclosure needs to meet some uniform criteria for when a differing outcome rises to the level that the disclosure is compelled.

Data exist for pneumonia outcomes, readmission rates, and medication errors, as well as data for physicians relative to their colleagues. The fact that a hospitalist might have incidental knowledge of differing outcomes is not sufficient to create an ethical obligation, but there must be some uniformity to a disclosure requirement.

It is easy to envision a hospitalist spending as much time disclosing outcomes data as disclosing medical information and prognosis in the process of obtaining informed consent. Hospitalists can’t be expected to manage all of that information, much less make a meaningful disclosure. Physicians’ information-management skills should focus on medical knowledge—not outcomes data.

The test case has more implications for the professionalism of the hospitalist. Ultimately, they should act in the best interest of the patient. The recommended course of treatment should maximize benefit and minimize harm. Enough information should be provided that the patient can participate in weighing risks and benefits. The hospitalist needs to decide if it is unsafe to perform the procedure at their institution, and if so, the patient should be referred out. If there is a small but real benefit to having the procedure done elsewhere, the hospitalist cannot be responsible for determining what threshold of incremental benefit warrants disclosure. Existing ethical responsibilities to protect the patient and act in their best interests already addresses the issues of disparate outcomes more effectively than a blanket disclosure policy. Patients need to trust their hospitalists, and we need to be worthy of that trust.

Mandating disclosure of better outcomes would create a conflict of interest for physicians and hospitals. This conflict would be difficult to manage. Large referral centers exist because physicians recognize their own limits and act in patients’ best interests. Requiring a new level of disclosure would mean that many hospitals (save for an elite few) would recommend patients go elsewhere a substantial part of the time.

Conflicts of interest usually are managed more than eliminated, and the current management of the tension between caring for a patient personally and referring them out based on a perception of the patient’s need for a higher level of care achieves a reasonable and balanced result. Disrupting this result with a mandated level of disclosure will result in disruption of a functional process.

Measured disclosure of relevant information is a good thing. A high level of communication and shared decision-making between physicians and patients is a good thing. Discussion of disparate outcomes may be an ethically important part of a treatment plan, but saying it is advisable in all cases is unnecessary, unmanageable, and inadvisable.

The opinions expressed herein are those of the authors and do not represent those of the Society of Hospital Medicine or The Hospitalist.

Editors’ note: Hospitalists face difficult decisions every day, including situations that don’t always have clear-cut answers. Beginning with this month’s “HM Debate,” The Hospitalist stares down the tough questions and presents all sides of the issues. This month’s question: You are discharging a patient after treatment for a non-ST segment myocardial infarction (NSTEMI). The cardiology team recommends nonemergent coronary artery bypass grafting (CABG) for the patient’s three-vessel disease. You set up a referral for surgery, but you know the CABG morbidity and mortality rates are higher at your hospital than at a hospital 30 miles away. Should you disclose this information to your patient?

PRO

If you would tell your relative, you should tell your patient

Dr. Brezina is a hospitalist at Durham Regional Hospital in North Carolina and a member of SHM’s Ethics Committee.

If a patient at your hospital needs surgery or another invasive intervention, are you obligated to inform them of your hospital’s record with that procedure—particularly if the record is not as good as the one of the hospital down the street? Should loyalty to your hospital trump the risk to the patient?

In our scenario, the patient is being referred for elective surgery, and it is known that the cardiovascular team at a neighboring hospital has a better record for this procedure. It is the hospitalist’s job to present this information to the patient so that an intelligent and informed decision can be made. If the hospitalist believes the outcomes data, then an obligation exists to share that information with the patient.

If the data are subtle, one might argue that confusing the patient with more levels of decision-making is unnecessary. On the other hand, if data on performance outcomes between two institutions are clear, it presents an ethical position.

Let us assume the hospitalist is aware of poor outcomes in coronary bypass surgery at their hospital. Perhaps the mortality rates were unusually high and the hospitalist knew external consultants were brought in to identify the problems. Would you refer your patient for bypass surgery in that situation? A better question might be: Would you let a family member undergo coronary artery bypass grafting (CABG) in your hospital? Probably not. So if you would inform a family member, shouldn’t you tell your patient?

A situation like this occurred in September 2005 at the University of Massachusetts Medical Center in Worcester. Media coverage was intense, and statistics showed that thoracic surgery mortality at UMass was the highest in the state two years running. The service at the hospital was closed temporarily.1 Extensive reorganization, adoption of QI protocols, and development of oversight committees resulted in much-improved patient outcomes when the program reopened a few weeks later.

The higher-than-expected complication rate had persisted at UMass for four years before the closure and reorganization. One wonders if hospitalists and cardiologists suspected a problem with surgical outcomes before the hospital was thrust into the national spotlight. Is it our job to know our hospital’s track record in surgery and invasive procedures? Yes, it probably is. This is why a hospital’s quality-assurance committee is so important. As keeper of the outcomes data, the committee is charged with sounding an alarm when a problem is brewing.

Tech-savvy patients have access to detailed reporting on performance measures for hospitals and physicians. Interpretation of the data can be complex. High surgical complication rates might be the result of a higher-than-expected patient acuity mix—patients who were older and sicker than usual—and may not represent a system or surgeon problem. Hospitalists need to guide patients through the interpretation of this data.

Patients trust their physicians. They trust that hospitalists will provide the best advice and make recommendations with their interests at heart. To not do so violates the public trust in physicians as patient advocates. Required by law, transparency of hospital quality data is the basis of a truthful relationship between the healthcare system and the public.

HM’s reputation will be tarnished if patients perceive that the physicians are more interested in the well-being of the hospital than the well-being of the patients.

Reference

1. Kowalczyk L, Smith S. Hospital halts heart surgeries due to deaths. Boston Globe Web site. Available at: www.boston.com/news/local/articles/2005/09/22/hospital_halts_heart_surgeries_due_to_deaths. Accessed March 31, 2009.

CON

Outcome disclosure is impractical, unnecessary

Dr. Egan is a hospitalist at the University of Colorado Denver and chair of SHM’s Ethics Committee.

At first glance, disclosing information about better outcomes at another hospital seems reasonable—even ethically obligatory. However, there are several competing interests, and in the end, the existing precedent for requiring reasonable disclosure in informed consent makes more sense.

The first issue is practicality. How much is a hospitalist obligated to know, and what degree of difference must be disclosed? In the case example, the hospitalist knows better outcomes are available at a nearby facility. However, if a duty to disclose this information exists, it can’t be limited to the information that an individual hospitalist has available to them. If such a duty exists, there is a corresponding burden on providers to have consistent and accurate information to disclose. If disclosure of differing outcomes is the ethical standard, then the reasonable disclosure needs to meet some uniform criteria for when a differing outcome rises to the level that the disclosure is compelled.

Data exist for pneumonia outcomes, readmission rates, and medication errors, as well as data for physicians relative to their colleagues. The fact that a hospitalist might have incidental knowledge of differing outcomes is not sufficient to create an ethical obligation, but there must be some uniformity to a disclosure requirement.

It is easy to envision a hospitalist spending as much time disclosing outcomes data as disclosing medical information and prognosis in the process of obtaining informed consent. Hospitalists can’t be expected to manage all of that information, much less make a meaningful disclosure. Physicians’ information-management skills should focus on medical knowledge—not outcomes data.

The test case has more implications for the professionalism of the hospitalist. Ultimately, they should act in the best interest of the patient. The recommended course of treatment should maximize benefit and minimize harm. Enough information should be provided that the patient can participate in weighing risks and benefits. The hospitalist needs to decide if it is unsafe to perform the procedure at their institution, and if so, the patient should be referred out. If there is a small but real benefit to having the procedure done elsewhere, the hospitalist cannot be responsible for determining what threshold of incremental benefit warrants disclosure. Existing ethical responsibilities to protect the patient and act in their best interests already addresses the issues of disparate outcomes more effectively than a blanket disclosure policy. Patients need to trust their hospitalists, and we need to be worthy of that trust.

Mandating disclosure of better outcomes would create a conflict of interest for physicians and hospitals. This conflict would be difficult to manage. Large referral centers exist because physicians recognize their own limits and act in patients’ best interests. Requiring a new level of disclosure would mean that many hospitals (save for an elite few) would recommend patients go elsewhere a substantial part of the time.

Conflicts of interest usually are managed more than eliminated, and the current management of the tension between caring for a patient personally and referring them out based on a perception of the patient’s need for a higher level of care achieves a reasonable and balanced result. Disrupting this result with a mandated level of disclosure will result in disruption of a functional process.

Measured disclosure of relevant information is a good thing. A high level of communication and shared decision-making between physicians and patients is a good thing. Discussion of disparate outcomes may be an ethically important part of a treatment plan, but saying it is advisable in all cases is unnecessary, unmanageable, and inadvisable.

The opinions expressed herein are those of the authors and do not represent those of the Society of Hospital Medicine or The Hospitalist.

Sen. Max Baucus (D-Mont.) might be the most devoted champion of healthcare reform on Capitol Hill today. He chairs the Senate Finance Committee, which has jurisdiction over Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and other healthcare entitlement programs. He has worked for healthcare reform in large and small measures, and recently put forth a comprehensive—and controversial—plan for changing the U.S. healthcare system.

Sen. Baucus penned a white paper, “Call to Action: Health Care Reform 2009,” which was published after the November election and outlines his proposals for universal healthcare coverage. Although he hopes to introduce some form of his white paper as a Senate bill, as of press time, he had not done so.

A Stanford Law graduate, Sen. Baucus was the executive director of the 1972 Montana Constitutional Convention, which rewrote that state’s constitution. He has served in public office since 1973, including six consecutive terms in the U.S. Senate.

The Hospitalist caught up with Sen. Baucus to discuss national healthcare reform and how hospitalists can—and will—factor into the changes.

Question: You are pushing for action on healthcare reform in 2009. What’s the status of your first piece of healthcare legislation this year?

Answer: My goal is to craft consensus legislation and move it through the Congress and into law. Now that Congress has passed the American Recovery and Reinvestment Act, I intend to return the attention of the Finance Committee to health reform.

Q: Where will funding come from for some of the immediate healthcare initiatives you’d like to see?

A: Healthcare reform will require an upfront investment in order to achieve the savings we all know are possible. It is my intention that after 10 years, the U.S. will spend no more on healthcare than is currently projected, but we will spend those resources more efficiently and will provide better-quality coverage to all Americans. One of the reasons healthcare reform is so important is that if we ignore the problems in the system and fail to act, healthcare costs will only grow. Acting now is a cost-saving proposition.

Q: As coverage is provided for more Americans, what steps should be taken to ensure an adequate number of physicians, hospital beds, clinics, etc.?

A: With more people in the healthcare system, we will need more physicians and resources. My plan increases the number of primary-care doctors by strengthening the role of primary care. Today, America’s system undervalues primary care relative to specialty care. This has caused fewer medical students to choose careers in primary care. My plan will increase the supply of primary-care practitioners by using federal reimbursement systems and other means to improve the value placed on their work.

My plan also builds on existing resources that have been successful in delivering primary-care services, like community health centers. The proposal I’ve put forward increases funding for low-income and rural clinics designated by Medicare as Federally Qualified Health Centers. [It would provide] more funding for Rural Health Clinics. By strengthening community and rural providers, we can improve access to primary care and better manage conditions before they become serious. That will keep people healthier and save money in the long run.

Q: You call for refocusing payment incentives from quantity of care to quality of care. Do you have CMS’ Physician Quality Reporting Initiative (PQRI) in mind to help move the focus of compensation?

A: My plan builds on a number of programs that are already in place to improve the quality of care, including PQRI, which provides incentives for physicians who track and report data on the quality of care they provide. My plan would expand this initiative using cutting-edge technology to collect and analyze data on quality, and improve it by increasing outreach, information, and assistance to doctors who participate in the program. ... My plan would expand gain-sharing programs, which allow providers to share savings from improved efficiency and quality.

Q: SHM has identified improvements in care coordination, particularly as patients transition from the hospital to the home, as an important element of health reform. You, too, have identified this as priority. Can you elaborate on the types of proposals to improve care transitions that we might see in your healthcare reform bill?

A: Today’s healthcare system doesn’t do enough to encourage healthcare providers to work together, which can be particularly detrimental for patients who are transitioning from hospital to home. According to some estimates, 18% of Medicare hospital admissions result in a rehospitalization within 30 days. This is simply unacceptable, and it is avoidable. Providers can work better together to ensure that patients receive proper follow-up care post-discharge.

In my blueprint for reform, I laid out a series of proposals to encourage greater collaboration among providers. These proposals include a plan to reduce hospital readmissions through increasing public disclosure around readmission rates and, in later years, reducing payment rates for hospitals with readmissions above a certain benchmark. My plan also identifies “bundling” hospital and physician payments under Medicare as a way to encourage greater provider collaboration across a patient’s episode of care, and other concepts like the development of accountable care organizations. My hope is that these proposals will encourage and reward health providers who work together to provide patients the best possible care.

Q: Regarding value-based purchasing, your paper states, “Every effort must be made to align hospital and physician quality goals.” Would this alignment apply to bonus payments, and if so, will it necessitate loosening current restrictions on gain-sharing?

A: Successful implementation of new payment and delivery system models may require changes to the regulatory structure governing provider collaboration. ... It is critical that we strike an appropriate balance between offering providers incentives to work together while also protecting against financial conflicts of interest that could negatively impact quality of care. Regarding value-based purchasing, we are continuing to explore ways to encourage hospitals and doctors to work together to improve quality and are evaluating the best way to align payment incentives to meet this goal.

Q: How can hospitalists help with healthcare reform efforts?

A: As is true with all members of the healthcare community, I encourage hospitalists to work with me and my colleagues throughout the reform process. It is certain to take significant cooperation to create a more accessible, lower-cost, higher-quality system, but I’m confident that working together, we will succeed. I’m asking everyone in the healthcare community to help me create a “can-do” environment for healthcare reform. All stakeholders have a particular focus, and I am willing to listen to every issue. But our collective focus should be on [making] the health system better for everyone.

As always, I appreciate all questions, comments, and concerns, and I look forward to working with all stakeholders throughout this process. TH

Jane Jerrard is a medical writer based in Chicago.

Sen. Max Baucus (D-Mont.) might be the most devoted champion of healthcare reform on Capitol Hill today. He chairs the Senate Finance Committee, which has jurisdiction over Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and other healthcare entitlement programs. He has worked for healthcare reform in large and small measures, and recently put forth a comprehensive—and controversial—plan for changing the U.S. healthcare system.

Sen. Baucus penned a white paper, “Call to Action: Health Care Reform 2009,” which was published after the November election and outlines his proposals for universal healthcare coverage. Although he hopes to introduce some form of his white paper as a Senate bill, as of press time, he had not done so.

A Stanford Law graduate, Sen. Baucus was the executive director of the 1972 Montana Constitutional Convention, which rewrote that state’s constitution. He has served in public office since 1973, including six consecutive terms in the U.S. Senate.

The Hospitalist caught up with Sen. Baucus to discuss national healthcare reform and how hospitalists can—and will—factor into the changes.

Question: You are pushing for action on healthcare reform in 2009. What’s the status of your first piece of healthcare legislation this year?

Answer: My goal is to craft consensus legislation and move it through the Congress and into law. Now that Congress has passed the American Recovery and Reinvestment Act, I intend to return the attention of the Finance Committee to health reform.

Q: Where will funding come from for some of the immediate healthcare initiatives you’d like to see?

A: Healthcare reform will require an upfront investment in order to achieve the savings we all know are possible. It is my intention that after 10 years, the U.S. will spend no more on healthcare than is currently projected, but we will spend those resources more efficiently and will provide better-quality coverage to all Americans. One of the reasons healthcare reform is so important is that if we ignore the problems in the system and fail to act, healthcare costs will only grow. Acting now is a cost-saving proposition.

Q: As coverage is provided for more Americans, what steps should be taken to ensure an adequate number of physicians, hospital beds, clinics, etc.?

A: With more people in the healthcare system, we will need more physicians and resources. My plan increases the number of primary-care doctors by strengthening the role of primary care. Today, America’s system undervalues primary care relative to specialty care. This has caused fewer medical students to choose careers in primary care. My plan will increase the supply of primary-care practitioners by using federal reimbursement systems and other means to improve the value placed on their work.

My plan also builds on existing resources that have been successful in delivering primary-care services, like community health centers. The proposal I’ve put forward increases funding for low-income and rural clinics designated by Medicare as Federally Qualified Health Centers. [It would provide] more funding for Rural Health Clinics. By strengthening community and rural providers, we can improve access to primary care and better manage conditions before they become serious. That will keep people healthier and save money in the long run.

Q: You call for refocusing payment incentives from quantity of care to quality of care. Do you have CMS’ Physician Quality Reporting Initiative (PQRI) in mind to help move the focus of compensation?

A: My plan builds on a number of programs that are already in place to improve the quality of care, including PQRI, which provides incentives for physicians who track and report data on the quality of care they provide. My plan would expand this initiative using cutting-edge technology to collect and analyze data on quality, and improve it by increasing outreach, information, and assistance to doctors who participate in the program. ... My plan would expand gain-sharing programs, which allow providers to share savings from improved efficiency and quality.

Q: SHM has identified improvements in care coordination, particularly as patients transition from the hospital to the home, as an important element of health reform. You, too, have identified this as priority. Can you elaborate on the types of proposals to improve care transitions that we might see in your healthcare reform bill?

A: Today’s healthcare system doesn’t do enough to encourage healthcare providers to work together, which can be particularly detrimental for patients who are transitioning from hospital to home. According to some estimates, 18% of Medicare hospital admissions result in a rehospitalization within 30 days. This is simply unacceptable, and it is avoidable. Providers can work better together to ensure that patients receive proper follow-up care post-discharge.

In my blueprint for reform, I laid out a series of proposals to encourage greater collaboration among providers. These proposals include a plan to reduce hospital readmissions through increasing public disclosure around readmission rates and, in later years, reducing payment rates for hospitals with readmissions above a certain benchmark. My plan also identifies “bundling” hospital and physician payments under Medicare as a way to encourage greater provider collaboration across a patient’s episode of care, and other concepts like the development of accountable care organizations. My hope is that these proposals will encourage and reward health providers who work together to provide patients the best possible care.

Q: Regarding value-based purchasing, your paper states, “Every effort must be made to align hospital and physician quality goals.” Would this alignment apply to bonus payments, and if so, will it necessitate loosening current restrictions on gain-sharing?

A: Successful implementation of new payment and delivery system models may require changes to the regulatory structure governing provider collaboration. ... It is critical that we strike an appropriate balance between offering providers incentives to work together while also protecting against financial conflicts of interest that could negatively impact quality of care. Regarding value-based purchasing, we are continuing to explore ways to encourage hospitals and doctors to work together to improve quality and are evaluating the best way to align payment incentives to meet this goal.

Q: How can hospitalists help with healthcare reform efforts?

A: As is true with all members of the healthcare community, I encourage hospitalists to work with me and my colleagues throughout the reform process. It is certain to take significant cooperation to create a more accessible, lower-cost, higher-quality system, but I’m confident that working together, we will succeed. I’m asking everyone in the healthcare community to help me create a “can-do” environment for healthcare reform. All stakeholders have a particular focus, and I am willing to listen to every issue. But our collective focus should be on [making] the health system better for everyone.

As always, I appreciate all questions, comments, and concerns, and I look forward to working with all stakeholders throughout this process. TH

Jane Jerrard is a medical writer based in Chicago.

Sen. Max Baucus (D-Mont.) might be the most devoted champion of healthcare reform on Capitol Hill today. He chairs the Senate Finance Committee, which has jurisdiction over Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and other healthcare entitlement programs. He has worked for healthcare reform in large and small measures, and recently put forth a comprehensive—and controversial—plan for changing the U.S. healthcare system.

Sen. Baucus penned a white paper, “Call to Action: Health Care Reform 2009,” which was published after the November election and outlines his proposals for universal healthcare coverage. Although he hopes to introduce some form of his white paper as a Senate bill, as of press time, he had not done so.

A Stanford Law graduate, Sen. Baucus was the executive director of the 1972 Montana Constitutional Convention, which rewrote that state’s constitution. He has served in public office since 1973, including six consecutive terms in the U.S. Senate.

The Hospitalist caught up with Sen. Baucus to discuss national healthcare reform and how hospitalists can—and will—factor into the changes.

Question: You are pushing for action on healthcare reform in 2009. What’s the status of your first piece of healthcare legislation this year?

Answer: My goal is to craft consensus legislation and move it through the Congress and into law. Now that Congress has passed the American Recovery and Reinvestment Act, I intend to return the attention of the Finance Committee to health reform.

Q: Where will funding come from for some of the immediate healthcare initiatives you’d like to see?

A: Healthcare reform will require an upfront investment in order to achieve the savings we all know are possible. It is my intention that after 10 years, the U.S. will spend no more on healthcare than is currently projected, but we will spend those resources more efficiently and will provide better-quality coverage to all Americans. One of the reasons healthcare reform is so important is that if we ignore the problems in the system and fail to act, healthcare costs will only grow. Acting now is a cost-saving proposition.

Q: As coverage is provided for more Americans, what steps should be taken to ensure an adequate number of physicians, hospital beds, clinics, etc.?

A: With more people in the healthcare system, we will need more physicians and resources. My plan increases the number of primary-care doctors by strengthening the role of primary care. Today, America’s system undervalues primary care relative to specialty care. This has caused fewer medical students to choose careers in primary care. My plan will increase the supply of primary-care practitioners by using federal reimbursement systems and other means to improve the value placed on their work.

My plan also builds on existing resources that have been successful in delivering primary-care services, like community health centers. The proposal I’ve put forward increases funding for low-income and rural clinics designated by Medicare as Federally Qualified Health Centers. [It would provide] more funding for Rural Health Clinics. By strengthening community and rural providers, we can improve access to primary care and better manage conditions before they become serious. That will keep people healthier and save money in the long run.

Q: You call for refocusing payment incentives from quantity of care to quality of care. Do you have CMS’ Physician Quality Reporting Initiative (PQRI) in mind to help move the focus of compensation?

A: My plan builds on a number of programs that are already in place to improve the quality of care, including PQRI, which provides incentives for physicians who track and report data on the quality of care they provide. My plan would expand this initiative using cutting-edge technology to collect and analyze data on quality, and improve it by increasing outreach, information, and assistance to doctors who participate in the program. ... My plan would expand gain-sharing programs, which allow providers to share savings from improved efficiency and quality.

Q: SHM has identified improvements in care coordination, particularly as patients transition from the hospital to the home, as an important element of health reform. You, too, have identified this as priority. Can you elaborate on the types of proposals to improve care transitions that we might see in your healthcare reform bill?

A: Today’s healthcare system doesn’t do enough to encourage healthcare providers to work together, which can be particularly detrimental for patients who are transitioning from hospital to home. According to some estimates, 18% of Medicare hospital admissions result in a rehospitalization within 30 days. This is simply unacceptable, and it is avoidable. Providers can work better together to ensure that patients receive proper follow-up care post-discharge.

In my blueprint for reform, I laid out a series of proposals to encourage greater collaboration among providers. These proposals include a plan to reduce hospital readmissions through increasing public disclosure around readmission rates and, in later years, reducing payment rates for hospitals with readmissions above a certain benchmark. My plan also identifies “bundling” hospital and physician payments under Medicare as a way to encourage greater provider collaboration across a patient’s episode of care, and other concepts like the development of accountable care organizations. My hope is that these proposals will encourage and reward health providers who work together to provide patients the best possible care.

Q: Regarding value-based purchasing, your paper states, “Every effort must be made to align hospital and physician quality goals.” Would this alignment apply to bonus payments, and if so, will it necessitate loosening current restrictions on gain-sharing?

A: Successful implementation of new payment and delivery system models may require changes to the regulatory structure governing provider collaboration. ... It is critical that we strike an appropriate balance between offering providers incentives to work together while also protecting against financial conflicts of interest that could negatively impact quality of care. Regarding value-based purchasing, we are continuing to explore ways to encourage hospitals and doctors to work together to improve quality and are evaluating the best way to align payment incentives to meet this goal.

Q: How can hospitalists help with healthcare reform efforts?

A: As is true with all members of the healthcare community, I encourage hospitalists to work with me and my colleagues throughout the reform process. It is certain to take significant cooperation to create a more accessible, lower-cost, higher-quality system, but I’m confident that working together, we will succeed. I’m asking everyone in the healthcare community to help me create a “can-do” environment for healthcare reform. All stakeholders have a particular focus, and I am willing to listen to every issue. But our collective focus should be on [making] the health system better for everyone.

As always, I appreciate all questions, comments, and concerns, and I look forward to working with all stakeholders throughout this process. TH

Jane Jerrard is a medical writer based in Chicago.

Hospitalists who are planning on advancing their careers—particularly those working toward leadership roles—need to acquire or sharpen their skills through additional training: conferences and seminars, online courses, self-study, or university classes.

The Hospitalist spoke with several HM leaders and a physician executive coach about what makes an employee promotion material. Here are their “continuing education” suggestions for ambitious hospitalists.

Invest in Yourself

The first step in selecting a training venue is to identify your goal. What do you need to learn? How much time, effort, and money do you want to devote to the training? “There are avenues for physicians to pursue if they want to develop some leadership skills,” says Francine R. Gaillour, MD, MBA, FACPE, executive director of the Physician Coaching Institute in Bellevue, Wash.

One route, which requires a considerable investment, is to pursue a master’s of business administration (MBA) degree. “I don’t recommend this for most physicians. However, a lot of physicians choose this,” Dr. Gaillour says. “It will help mainly on the business side of becoming a leader, and there are several MBA programs that cater specifically to physicians, or to healthcare.”

A number of the nation’s top universities offer advanced degrees for physicians, including:

• The University of Tennessee offers a physician executive MBA;
• The University of California at Irvine offers a healthcare executive MBA;
• The University of South Florida offers an executive MBA for physicians; and
• The University of Massachusetts offers an MBA program through the American College of Physician Executives (ACPE).

For many hospitalist leaders, an MBA is not necessary. Instead, you might prefer to sign up for a certificate program or short-term course in physician leadership. “For example, here in my area, the University of Washington offers a nine-month course in medical management,” Dr. Gaillour explains. “You attend one evening a week, and it covers the essential concepts in being a leader in the medical field. The course kind of skims the surface of a number of important topics.”

A practical—and popular—way to acquire targeted training is by taking focused leadership courses and workshops offered by such organizations as SHM or ACPE.

Start with SHM

As the chair of SHM’s Leadership Committee, Eric Howell, MD, FHM, SHM board member and director of Collaborative Inpatient Medicine Service in the Department of Medicine at Johns Hopkins Bayview Medical Center in Baltimore, is closely involved in the society’s Leadership Academy. “Anybody can sign up for this—hospitalists, nonphysicians, even administrators,” he explains. “Level 1 has no prerequisites, and Level 2 requires only that you’ve completed Level 1 or something equivalent.”

The Level 1 Academy is “probably best for those looking to improve their leadership skills in whatever venue they’re in—an HM group, nursing unit, you name it,” Dr. Howell says. “You can use it to figure out what you need more help with and then branch out to an ACPE [course] or something like that—even an MBA program.”

The next Leadership Academy is Sept. 14-17 in Miami.

Physician-Specific Leadership Courses

ACPE offers a wealth of physician leadership education options, including live and online courses. The core curriculum includes courses that cover the basics of negotiation, managing physicians, finance, and more. ACPE also offers courses that count toward four different medical management degrees, including an MBA.

“The ACPE is probably the No. 1 resource for physicians who want to develop skills in leadership,” says Dr. Gaillour, who is an ACPE fellow. “Their core courses are valuable, as well as fun and interesting. Beyond the basics, you can go as deep as you want in a specific area. About one-third of their curriculum is newer topics for more experienced physicians.”

Dr. Howell says ACPE courses “get a lot of traction among the leadership [committee]. They have courses relevant to hospitalists and hospital leaders.”

Patience Agborbesong, MD, has completed several ACPE courses. Currently an assistant professor as well as the medical director of the hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., Dr. Agborbesong first discovered ACPE courses as a newly promoted HM group director. “I took ‘Managing Physician Performance,’ a Web-based class with an actual instructor,” she says. “That course was particularly helpful to me. It covered interviewing job candidates, giving feedback and performance reviews, and dealing with disruptive individuals.”

One difference between SHM’s Leadership Academy and ACPE courses is class makeup. SHM’s Academy attracts a hospitalist crowd; physicians from all specialties attend ACPE courses. “I like the SHM Leadership Academy because it focuses on the hospital environment,” Dr. Agborbesong says, “but the ACPE is good, too, because I like to know how other worlds work—like private practice.”

Teach the Teacher

For academic hospitalists, a whole subset of specialized training exists, including the new Academic Hospitalist Academy. Co-sponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM), the academy will teach the practical knowledge, skills, and attitudes necessary to succeed as an academic hospitalist.

“The first one will take place in November,” says Jeffrey Wiese, MD, FACP, FHM, SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New Orleans, as well as associate chairman of medicine and director of the Tulane Internal Medicine Residency Program. The four-day course “covers teaching, working on research, and generally putting together a portfolio of academic work. It will also include some education on quality, knowing that academic hospitalists do a lot of research on this.”

Dr. Weise also recommends the Teaching Hospital Educators (THE) Course: “What Clinical Teachers in Hospital Medicine Need to Know.” It is offered as a pre-course at HM09 this month in Chicago. It debuted at the 2008 annual meeting and drew rave reviews, Dr. Wiese says. “This is a one-day course that focuses on the teaching component of being an academic hospitalist,” he says.

In-House Opportunities

Don’t overlook training opportunities offered by your group or institution, as they can help you save on travel and registration costs. “Investing yourself in whatever you have available is essential,” Dr. Howell stresses. “Most organizations have some leadership training, or some mentorship program. Even if it’s something like a course on dealing with difficult people offered by your human resources department, this is a great place to start, especially for those hospitalists just beginning to think about leadership.”

A side benefit of taking training offered by your employer is that you’ll position yourself for further training at your organization’s expense: “Many groups are willing to invest in their leaders, and I think they would give you CME money for leadership training … if you’ve demonstrated your interest by going to those free [in-house] courses, or taken it upon yourself to take a community college class or an online course,” Dr. Howell says. “This shows you’re ready to invest in yourself.”

Dr. Agborbesong helped compile a list of leadership training resources, which is available on SHM’s Web site at www.hospitalmedicine.org/LeadershipSpecialInterest. TH

Jane Jerrard is a freelance writer based in Chicago. She also writes Public Policy for The Hospitalist.

Hospitalists who are planning on advancing their careers—particularly those working toward leadership roles—need to acquire or sharpen their skills through additional training: conferences and seminars, online courses, self-study, or university classes.

The Hospitalist spoke with several HM leaders and a physician executive coach about what makes an employee promotion material. Here are their “continuing education” suggestions for ambitious hospitalists.

Invest in Yourself

The first step in selecting a training venue is to identify your goal. What do you need to learn? How much time, effort, and money do you want to devote to the training? “There are avenues for physicians to pursue if they want to develop some leadership skills,” says Francine R. Gaillour, MD, MBA, FACPE, executive director of the Physician Coaching Institute in Bellevue, Wash.

One route, which requires a considerable investment, is to pursue a master’s of business administration (MBA) degree. “I don’t recommend this for most physicians. However, a lot of physicians choose this,” Dr. Gaillour says. “It will help mainly on the business side of becoming a leader, and there are several MBA programs that cater specifically to physicians, or to healthcare.”

A number of the nation’s top universities offer advanced degrees for physicians, including:

• The University of Tennessee offers a physician executive MBA;
• The University of California at Irvine offers a healthcare executive MBA;
• The University of South Florida offers an executive MBA for physicians; and
• The University of Massachusetts offers an MBA program through the American College of Physician Executives (ACPE).

For many hospitalist leaders, an MBA is not necessary. Instead, you might prefer to sign up for a certificate program or short-term course in physician leadership. “For example, here in my area, the University of Washington offers a nine-month course in medical management,” Dr. Gaillour explains. “You attend one evening a week, and it covers the essential concepts in being a leader in the medical field. The course kind of skims the surface of a number of important topics.”

A practical—and popular—way to acquire targeted training is by taking focused leadership courses and workshops offered by such organizations as SHM or ACPE.

Start with SHM

As the chair of SHM’s Leadership Committee, Eric Howell, MD, FHM, SHM board member and director of Collaborative Inpatient Medicine Service in the Department of Medicine at Johns Hopkins Bayview Medical Center in Baltimore, is closely involved in the society’s Leadership Academy. “Anybody can sign up for this—hospitalists, nonphysicians, even administrators,” he explains. “Level 1 has no prerequisites, and Level 2 requires only that you’ve completed Level 1 or something equivalent.”

The Level 1 Academy is “probably best for those looking to improve their leadership skills in whatever venue they’re in—an HM group, nursing unit, you name it,” Dr. Howell says. “You can use it to figure out what you need more help with and then branch out to an ACPE [course] or something like that—even an MBA program.”

The next Leadership Academy is Sept. 14-17 in Miami.

Physician-Specific Leadership Courses

ACPE offers a wealth of physician leadership education options, including live and online courses. The core curriculum includes courses that cover the basics of negotiation, managing physicians, finance, and more. ACPE also offers courses that count toward four different medical management degrees, including an MBA.

“The ACPE is probably the No. 1 resource for physicians who want to develop skills in leadership,” says Dr. Gaillour, who is an ACPE fellow. “Their core courses are valuable, as well as fun and interesting. Beyond the basics, you can go as deep as you want in a specific area. About one-third of their curriculum is newer topics for more experienced physicians.”

Dr. Howell says ACPE courses “get a lot of traction among the leadership [committee]. They have courses relevant to hospitalists and hospital leaders.”

Patience Agborbesong, MD, has completed several ACPE courses. Currently an assistant professor as well as the medical director of the hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., Dr. Agborbesong first discovered ACPE courses as a newly promoted HM group director. “I took ‘Managing Physician Performance,’ a Web-based class with an actual instructor,” she says. “That course was particularly helpful to me. It covered interviewing job candidates, giving feedback and performance reviews, and dealing with disruptive individuals.”

One difference between SHM’s Leadership Academy and ACPE courses is class makeup. SHM’s Academy attracts a hospitalist crowd; physicians from all specialties attend ACPE courses. “I like the SHM Leadership Academy because it focuses on the hospital environment,” Dr. Agborbesong says, “but the ACPE is good, too, because I like to know how other worlds work—like private practice.”

Teach the Teacher

For academic hospitalists, a whole subset of specialized training exists, including the new Academic Hospitalist Academy. Co-sponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM), the academy will teach the practical knowledge, skills, and attitudes necessary to succeed as an academic hospitalist.

“The first one will take place in November,” says Jeffrey Wiese, MD, FACP, FHM, SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New Orleans, as well as associate chairman of medicine and director of the Tulane Internal Medicine Residency Program. The four-day course “covers teaching, working on research, and generally putting together a portfolio of academic work. It will also include some education on quality, knowing that academic hospitalists do a lot of research on this.”

Dr. Weise also recommends the Teaching Hospital Educators (THE) Course: “What Clinical Teachers in Hospital Medicine Need to Know.” It is offered as a pre-course at HM09 this month in Chicago. It debuted at the 2008 annual meeting and drew rave reviews, Dr. Wiese says. “This is a one-day course that focuses on the teaching component of being an academic hospitalist,” he says.

In-House Opportunities

Don’t overlook training opportunities offered by your group or institution, as they can help you save on travel and registration costs. “Investing yourself in whatever you have available is essential,” Dr. Howell stresses. “Most organizations have some leadership training, or some mentorship program. Even if it’s something like a course on dealing with difficult people offered by your human resources department, this is a great place to start, especially for those hospitalists just beginning to think about leadership.”

A side benefit of taking training offered by your employer is that you’ll position yourself for further training at your organization’s expense: “Many groups are willing to invest in their leaders, and I think they would give you CME money for leadership training … if you’ve demonstrated your interest by going to those free [in-house] courses, or taken it upon yourself to take a community college class or an online course,” Dr. Howell says. “This shows you’re ready to invest in yourself.”

Dr. Agborbesong helped compile a list of leadership training resources, which is available on SHM’s Web site at www.hospitalmedicine.org/LeadershipSpecialInterest. TH

Jane Jerrard is a freelance writer based in Chicago. She also writes Public Policy for The Hospitalist.

Hospitalists who are planning on advancing their careers—particularly those working toward leadership roles—need to acquire or sharpen their skills through additional training: conferences and seminars, online courses, self-study, or university classes.

The Hospitalist spoke with several HM leaders and a physician executive coach about what makes an employee promotion material. Here are their “continuing education” suggestions for ambitious hospitalists.

Invest in Yourself

The first step in selecting a training venue is to identify your goal. What do you need to learn? How much time, effort, and money do you want to devote to the training? “There are avenues for physicians to pursue if they want to develop some leadership skills,” says Francine R. Gaillour, MD, MBA, FACPE, executive director of the Physician Coaching Institute in Bellevue, Wash.

One route, which requires a considerable investment, is to pursue a master’s of business administration (MBA) degree. “I don’t recommend this for most physicians. However, a lot of physicians choose this,” Dr. Gaillour says. “It will help mainly on the business side of becoming a leader, and there are several MBA programs that cater specifically to physicians, or to healthcare.”

A number of the nation’s top universities offer advanced degrees for physicians, including:

• The University of Tennessee offers a physician executive MBA;
• The University of California at Irvine offers a healthcare executive MBA;
• The University of South Florida offers an executive MBA for physicians; and
• The University of Massachusetts offers an MBA program through the American College of Physician Executives (ACPE).

For many hospitalist leaders, an MBA is not necessary. Instead, you might prefer to sign up for a certificate program or short-term course in physician leadership. “For example, here in my area, the University of Washington offers a nine-month course in medical management,” Dr. Gaillour explains. “You attend one evening a week, and it covers the essential concepts in being a leader in the medical field. The course kind of skims the surface of a number of important topics.”

A practical—and popular—way to acquire targeted training is by taking focused leadership courses and workshops offered by such organizations as SHM or ACPE.

Start with SHM

As the chair of SHM’s Leadership Committee, Eric Howell, MD, FHM, SHM board member and director of Collaborative Inpatient Medicine Service in the Department of Medicine at Johns Hopkins Bayview Medical Center in Baltimore, is closely involved in the society’s Leadership Academy. “Anybody can sign up for this—hospitalists, nonphysicians, even administrators,” he explains. “Level 1 has no prerequisites, and Level 2 requires only that you’ve completed Level 1 or something equivalent.”

The Level 1 Academy is “probably best for those looking to improve their leadership skills in whatever venue they’re in—an HM group, nursing unit, you name it,” Dr. Howell says. “You can use it to figure out what you need more help with and then branch out to an ACPE [course] or something like that—even an MBA program.”

The next Leadership Academy is Sept. 14-17 in Miami.

Physician-Specific Leadership Courses

ACPE offers a wealth of physician leadership education options, including live and online courses. The core curriculum includes courses that cover the basics of negotiation, managing physicians, finance, and more. ACPE also offers courses that count toward four different medical management degrees, including an MBA.

“The ACPE is probably the No. 1 resource for physicians who want to develop skills in leadership,” says Dr. Gaillour, who is an ACPE fellow. “Their core courses are valuable, as well as fun and interesting. Beyond the basics, you can go as deep as you want in a specific area. About one-third of their curriculum is newer topics for more experienced physicians.”

Dr. Howell says ACPE courses “get a lot of traction among the leadership [committee]. They have courses relevant to hospitalists and hospital leaders.”

Patience Agborbesong, MD, has completed several ACPE courses. Currently an assistant professor as well as the medical director of the hospitalist program at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., Dr. Agborbesong first discovered ACPE courses as a newly promoted HM group director. “I took ‘Managing Physician Performance,’ a Web-based class with an actual instructor,” she says. “That course was particularly helpful to me. It covered interviewing job candidates, giving feedback and performance reviews, and dealing with disruptive individuals.”

One difference between SHM’s Leadership Academy and ACPE courses is class makeup. SHM’s Academy attracts a hospitalist crowd; physicians from all specialties attend ACPE courses. “I like the SHM Leadership Academy because it focuses on the hospital environment,” Dr. Agborbesong says, “but the ACPE is good, too, because I like to know how other worlds work—like private practice.”

Teach the Teacher

For academic hospitalists, a whole subset of specialized training exists, including the new Academic Hospitalist Academy. Co-sponsored by SHM, the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM), the academy will teach the practical knowledge, skills, and attitudes necessary to succeed as an academic hospitalist.

“The first one will take place in November,” says Jeffrey Wiese, MD, FACP, FHM, SHM board member and associate professor of medicine at Tulane University Health Sciences Center in New Orleans, as well as associate chairman of medicine and director of the Tulane Internal Medicine Residency Program. The four-day course “covers teaching, working on research, and generally putting together a portfolio of academic work. It will also include some education on quality, knowing that academic hospitalists do a lot of research on this.”

Dr. Weise also recommends the Teaching Hospital Educators (THE) Course: “What Clinical Teachers in Hospital Medicine Need to Know.” It is offered as a pre-course at HM09 this month in Chicago. It debuted at the 2008 annual meeting and drew rave reviews, Dr. Wiese says. “This is a one-day course that focuses on the teaching component of being an academic hospitalist,” he says.

In-House Opportunities

Don’t overlook training opportunities offered by your group or institution, as they can help you save on travel and registration costs. “Investing yourself in whatever you have available is essential,” Dr. Howell stresses. “Most organizations have some leadership training, or some mentorship program. Even if it’s something like a course on dealing with difficult people offered by your human resources department, this is a great place to start, especially for those hospitalists just beginning to think about leadership.”

A side benefit of taking training offered by your employer is that you’ll position yourself for further training at your organization’s expense: “Many groups are willing to invest in their leaders, and I think they would give you CME money for leadership training … if you’ve demonstrated your interest by going to those free [in-house] courses, or taken it upon yourself to take a community college class or an online course,” Dr. Howell says. “This shows you’re ready to invest in yourself.”

Dr. Agborbesong helped compile a list of leadership training resources, which is available on SHM’s Web site at www.hospitalmedicine.org/LeadershipSpecialInterest. TH

Jane Jerrard is a freelance writer based in Chicago. She also writes Public Policy for The Hospitalist.