Medicolegal Issues

Each year a new team of SHM officers is elected to lend their wisdom, time, experience, and skills in a collaborative effort to help manage the business of our organization, drive new initiatives, and support the society’s mission. At this year’s annual meeting in Washington, D.C., we again witnessed that familiar changing of the guard with the following inductions:

• President Mary Jo Gorman, MD, MBA;
• President-Elect Russell Holman, MD;
• Treasurer Patrick Cawley, MD; and
• Secretary Jack Percelay, MD, MPH.

“Hospitalists are squarely in the spotlight today on key issues affecting patient care, quality of hospital care, hospital leadership, and other concerns. So it is important that we have a strong, hands-on leadership team that is committed to continuing the positive momentum SHM has generated for hospitalists,” says Larry Wellikson, MD, FACP, CEO of SHM. “I couldn’t be more thrilled with our slate of newly appointed officers. Time and again through the years Mary Jo, Rusty, Pat, and Jack have proven that they are active participants, and that they are leaders who will rise to the occasion to help us meet our objectives.”

Dr. Gorman, a charter member of SHM, has been a practicing hospitalist since 1997, when she founded the first hospitalist practice in St. Louis. In early 1999, her group merged into IPC—The Hospitalist Company and grew to become the dominant hospitalist group in the city. In 2001, Dr. Gorman was promoted to vice-president of medical affairs for IPC, responsible for the design and implementation of company-wide programs involving business development, recruitment, physician training, and operations in all of IPC’s markets. In 2003, she was named chief medical officer and today works with more than 300 physicians nationwide to develop programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and clinical studies.

A cum laude graduate of St. Louis University, Dr. Gorman earned a BA in Chemistry/Biology in 1981, then went on to earn her MD in 1984 from Southern Illinois University School of Medicine in Springfield. In 1996, she earned a MBA from Washington University, Olin School of Business, in St. Louis.

SHM’s new President-Elect Dr. Holman is senior vice president and national medical director for Cogent Healthcare, an organization that manages hospital medicine programs throughout the country. He is responsible for program implementation and management, quality systems reporting and auditing, physician leadership development, and data systems integration. Formerly, Dr. Holman was the medical director of Hospital Services for HealthPartners Medical Group & Clinics, part of HealthPartners, Inc. in Minnesota. There he also was the founder and director of the HPMG Fellowship Program in Hospital Medicine.

A long-time member of SHM, Dr. Holman served on the Board of Directors as treasurer from 2004-2005. He was previously chair of the Leadership Development Committee, chair of the Midwest Council, course director of the SHM Leadership Academy, and a member of the Public Policy Committee. In February 2006 he co-authored the “Update in Hospital Medicine,” which appeared in Annals of Internal Medicine. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine.

Through the years, Dr. Holman’s commitment to hospital medicine has helped produce nationally recognized standards in the areas of quality improvement activities, models of medical education, observation units, communication systems, compensation plans, case management, surgical co-management collaborations, and patient flow initiatives. Dr. Holman serves on two national editorial boards for medical publications and is currently co-authoring a comprehensive textbook and electronic decision support tool in hospital medicine.

 

Dr. Holman earned his MD from Washington University School of Medicine in St. Louis and trained as a resident and chief medical resident at the University of Minnesota in Minneapolis.

New Treasurer Dr. Cawley is a hospitalist at the Medical University of South Carolina in Charleston, where he currently serves as interim executive medical director of MUSC Medical Center. He previously served as the chief of the Section of Hospital Medicine, vice chairman of clinical affairs in the Department of Medicine, and associate executive medical director at MUSC Medical Center.

A charter member of SHM, Dr. Cawley has served on numerous committees and was previously secretary of the Board for the 2004-2005 term. He has worked in both academic and nonacademic hospitals and has served as a consultant to numerous hospitals in the development of hospital medicine programs.

Dr. Cawley received his Bachelor of Science in 1988 from the University of Scranton (Pa.) and his MD from Georgetown University School of Medicine in Washington, D.C. He completed an internal medicine residency at Duke University in Durham, N.C. Later this year, he will complete his MBA from the University of Massachusetts-Amherst.

SHM’s new secretary is Dr. Percelay. He is director of Virtua Inpatient Pediatrics, a large pediatric hospital medicine group in Southern New Jersey with 14 full-time hospitalists covering two hospitals. Since 1991, Dr. Percelay has worked in a variety of community-based settings including the general pediatric ward, pediatric sub-specialty units, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and the emergency department.

A charter member of SHM and one of the nation’s first pediatric hospitalists, Dr. Percelay currently holds the Pediatric Seat on the SHM Board, in addition to serving on the Public Policy Committee and co-chairing the Pediatric Committee. He has been intimately involved in collaborative Pediatric hospital medicine projects such as the PRIS research network and the Denver 2005 and 2007 Pediatric Hospital Medicine conferences.

Dr. Percelay is also the founding chairperson and immediate past chair of the American Academy of Pediatrics Section on Hospital Medicine and co-authored the AAP policy statement on pediatric hospitalists. He completed his medical school and pediatric training at the University of California at San Francisco, along with an MPH at the University of California at Berkeley.

SHM congratulates these new officers and thanks our 2005 officers (Steve Pantilat, MD, president, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary) for their exemplary work.

Annual Meeting e-Community a Success

If the feedback from attendees at this year’s Annual Meeting was any indication, the inaugural launch of SHM’s Annual Meeting e-Community was a success.

Each year, SHM’s Annual Meeting provides an opportunity for hospital medicine professionals to network with colleagues and take advantage of more than 40 educational sessions during the course of three days.

While the location for the meeting changes regularly, there is a constant desire within the Annual Meeting planning committee (a group of volunteer members) to improve the attendee experience. The Annual Meeting e-Community (AMeC) was designed with that in mind.

The AMeC effectively extended the reach of the annual meeting both before and after the event. Since early April, attendees have been able to access the handouts for the presentations that were given at the event and network with colleagues thanks to dedicated discussion communities. There are also listings of exhibitors scheduled to be in attendance and general information about Washington, D.C., on the AMeC.

Because of the positive feedback received, the e-Community will stay online through early July, giving attendees the chance to download presentations from sessions that they didn’t attend and make contact with colleagues they met while in Washington, D.C.

 

Attendees appreciated the ability to access meeting materials prior to the event. “The Annual Meeting e-Community gave me a great opportunity to really plan out the sessions that I wanted to attend prior to the meeting,” says William Rifkin, MD, a hospitalist from the Yale School of Medicine.

According to Joy Wittnebert, AMeC project manager, the site was launched in response to feedback from past annual meetings. “Attendees have been consistently telling us that they want to be able to customize their experience and have more opportunities to network with colleagues before and after the event,” she says.

In the coming months, SHM staff will work with the Annual Meeting Committee to analyze additional feedback and begin making plans for the 2007 version of the site.

SHM Education Committee Launches 18-Month Strategic Plan

Helping our members and the hospital medicine community advance in professional growth and development has been on center stage as seen in the SHM Education Committee’s recent completion of an 18-month strategic plan. The plan is a framework designed to guide staff and volunteer leadership as they work to expand the society’s current slate of educational offerings. Inherent in the framework’s design is a focus on taking advantage of the myriad new channels that have come online for delivering educational content.

The plan is rooted primarily in the recently released Core Competencies in Hospital Medicine. The Core Competencies are a benchmark for the development of curricula within the hospital medicine specialty.

“One of the most exciting parts of this plan is its connection to the Core Competencies,” says Geri Barnes, SHM’s director of education and quality initiatives. “The connection means that this is one of the strongest educational plans that the society has put forward.”

A driving force in the creation of this plan was the committee’s desire to expand SHM’s educational offerings through a variety of technologic venues. “In the coming year, our educational offerings will truly become multi-dimensional,” says Scott Johnson, SHM’s director of information services. “As we expand into audio CDs, podcasts, and Web-based offerings, more hospitalists will be able to take advantage of these learning opportunities, which will have profound effects on the hospital medicine movement.”

With the education plan approved by SHM’s Board of Directors at its recent meeting, the Education Committee, chaired by Preetha Basaviah, MD, from Stanford University, will turn its attention to the first stage of implementation—a complete needs analysis. Some research has already taken place as part of SHM’s ongoing internal quality improvement processes.

“The key to the success of our plan is that we will be integrating feedback from hospitalists throughout North America as we move forward,” says Dr. Basaviah. “Ultimately, this kind of communication will ensure that we reach our primary goal: to provide tools and resources that help hospital medicine professionals improve the quality of care that they provide.”

Stay tuned to The Hospitalist for updates on the committee’s progress and an advanced look at new educational products.

Palliative Care: a Core Competency for Hospitalists

By Theresa Kristopaitis, MD, with input from Howard Epstein, MD, and the SHM Palliative Care Task Force

Palliative care is focused on the relief of suffering and support for the best quality of life for patients facing serious, life-threatening, or advanced illness, as well as their families. Palliative care is a general approach to healthcare that should be routinely integrated with disease modifying therapies. It is also a growing practice specialty for appropriately trained healthcare professionals dedicating their practice to the delivery of palliative care services.1

 

Optimally palliative care is delivered through an interdisciplinary team consisting of physicians, nurses, chaplains, social workers, pharmacists, as well as other disciplines as patient/family needs warrant. Models of palliative care delivery include hospital-based inpatient consultation services, inpatient palliative care units, outpatient and home-based consultation services, and ambulatory clinics. Hospitalists are ideally positioned to start inpatient palliative care services and reap the professional and institutional benefits that palliative care offers. Tools to develop a program can be obtained through the Center to Advance Palliative Care (www.capc.org).

A Core Competency

The skills gained from developing expertise in palliative care are indispensable to hospitalists—even if they don’t formally work with a palliative care team. Palliative care itself is identified as a healthcare systems core competency of hospital medicine.2 In addition, other hospital medicine competencies overlap with those key to palliative care: pain management, care of the elderly patient and vulnerable populations, communication, hospitalist as consultant, team approach and multidisciplinary care, transitions of care, and medical ethics.3 For some of the most challenging, yet common, inpatient clinical scenarios, palliative care and hospital practice can become indistinguishable.

Inpatient Scenarios: How Can Palliative Care Help?

Scenario 1: A patient on chronic long-acting opiate therapy is admitted to the hospital with complaints of pain, nausea, and vomiting.

The appropriate assessment and management of pain is a patient’s right and an institution’s responsibility, yet it is often inadequate.4 Many barriers to effective pain management have been identified, including limited physician undergraduate and graduate training.4,5 A fundamental goal of palliative care is pain relief. In turn, expertise in the pathophysiology of pain and safe prescribing of opioid, non-opioid, and adjuvant analgesics is critical for palliative care physicians. Palliative care training and resources focus on principles of analgesic pharmacology, equianalgesia, changing routes of administration, control of continuous and breakthrough pain, opioid rotation, and adverse effects of analgesics. A comprehensive introduction to the fundamentals of pain management can be obtained via Education on Palliative and End of Life Care (www.epec.net.) Pain Management Module.

Non-pain symptoms can be as troubling for patients with advanced illness as pain. The formal assessment, reassessment, and management of common symptoms, including nausea, vomiting, dyspnea, constipation, fatigue, and delirium, are a primary domain of palliative medicine. Nausea and vomiting, for example, can become a demoralizing symptom complex. Stimuli to the vomiting center can arise from the cerebral cortex, vestibular apparatus, chemoreceptor zone, and gastrointestinal tract resulting in a broad etiologic differential diagnosis.

With a solid understanding of its pathogenesis and pharmacologic and non-pharmacologic therapeutic principles, nausea and vomiting can be treated in the vast majority of patients. Multiple agents addressing multiple mechanisms may be required. Even the nausea associated with complete bowel obstruction often can be successfully palliated, without the use of nasogastric tubes or surgery.6 The End of Life/Palliative Education Resource Center (www.eperc.mcw.edu) is one of many resources with tools to improve a hospitalist’s evaluation and treatment of non-pain physical symptoms.

Scenario 2: A patient with advanced heart failure and his family are overwhelmed by differing consultant opinions on the appropriateness of implantable cardioverter defibrillator (ICD) insertion.

Effective communication with patients is a core responsibility of both hospitalists and palliative care physicians. A complementary—and at times challenging—skill is the ability to promote communication and consensus about care among multiple specialist consultants. Ripamonti and colleagues write, “Almost invariably, the act of communication is an important part of therapy: Occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”6

 

The American Academy of Hospice and Palliative Medicine UNIPAC series is a resource for physicians to hone their general communication skills, as well as those more specific to palliative care, such as sharing news (often bad) with patients and families and engaging in therapeutic dialogue.8

Palliative care begins with establishing the goals of care with a patient.9 All physicians bring great value to patient care when they are skilled at negotiating goals of care. There are numerous possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. Ideally, goals of care should be discussed with patients and families as early as possible in the course of a serious, life-threatening illness. Establishing realistic and attainable goals of care assumes increased importance in the setting of advanced disease, where treatments intended to prolong life may become more burdensome than beneficial.9

As the reader may have experienced, too often these discussions have not taken place or are held late in the trajectory of illness, such as when patients are hospitalized for severe progressive disease or are facing imminent death.10 In the scenario of potential ICD insertion, conversations with patients to clarify device-specific goals are best accomplished before they are placed and in the context of a broader discussion of the patient’s general medical condition and overall goals for care.11 This type of discussion ultimately improves the informed consent process for ICDs and other technologies. ICD recipients should be guided to periodically revisit their goals, particularly when their health status significantly changes.11 Unlike for initial ICD placement, there are no guidelines for disabling already implanted ICDs. The opportunity to discuss this issue with a patient before a crisis or before they lose decision-making capacity is frequently lost and occurs all too often at life’s end.12

Scenario 3: An elderly debilitated woman with advanced cervical cancer has been hospitalized six times in the past two months. She is cared for at home. Her family is tired but they are doing “the best they can.” She is brought to the emergency department again with weakness.

Effective implementation of care management strategies for patients with life-threatening and advanced disease requires assessment of their physical, social, emotional, and spiritual concerns.1 Similarly, family caregivers have their own—often unvoiced—biopsychosocial stressors.13 Physicians directing patient care must appreciate the significance of these multiple issues, even if they are not comfortable or are ill-equipped to handle them on their own. The power of the interdisciplinary palliative care model is that team members evaluate the patient from different perspectives and pool their expertise in addressing the complex needs of their patients and families.8

In some multidisciplinary models, the onus may lie on the physician to recognize the patient and family needs and mobilize the appropriate resources. Coordination of care at home for patients in the later stages of chronic illness may seem daunting during hospital stays. However, by employing measures utilized by palliative care teams, such as reviewing the goals of care, introducing community resources to help patients and families manage at home, providing anticipatory grief and bereavement support, and considering hospice referral, discharge planning and transitions in care can be much more sustainable.14 With these interventions, patients, families, physicians, and hospitals all benefit.

Conclusion

Hospital-based palliative care programs are growing exponentially.15 Hospitalists are in a unique position to continue their development. Even if the time or circumstances are not yet right for you to become a part of a formal palliative care program, there are daily opportunities to reap rewards from the knowledge, attitudes, and skills that palliative care training offers.

 

References

1. National Consensus Project for Quality Palliative Care: The development of practice guidelines 2004. Available at www.nationalconsensusproject.org. Last accessed April 28, 2006.
2. Pistoria MJ, Amin AN, Dressler DD, et al. The core competencies in hospital medicine. J Hosp Med. 2006;1:2(S1).
3. American Board of Hospice and Palliative Medicine. Available at www.abhpm.org. Last accessed April 28, 2006.
4. Phillips DM. JCAHO pain management standards unveiled. JAMA. 2000;284:428-429.
5. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685-695.
6. Ripamonti C, De Conno F, Ventafridda V, et al. Management of bowel obstruction in advanced and terminal cancer patients. Ann Oncol. 1993 Jan;4(1):15-21.
7. Buckman R. Communication in palliative care: a practical guide. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford Community Press; 1993:47-61.
8. Storey P, Knight CF. UNIPAC five—caring for the terminally ill—communication and the physician’s role in the interdisciplinary team. In: Hospice/Palliative Care Training for Physicians—A Self Study Program. New York: Mary Ann Liebert; 2003:1-147.
9. Morrison RS, Meier DE. Palliative care. NEJM. 2004;350:2582-2590.
10. Quill TE. Initiating end of life discussion with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284:2502-2507.
11. Berger, JT. The ethics of deactivating implanted cardioverter defibrillators. Ann Intern Med. 2005;142:631-634.
12. Goldstein NE, Lampert R, Bradely E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141:835-838.
13. Levine C. The loneliness of the long-term caregiver. NEJM. 1999;340:1587-1590.
14. Meier D. Palliative care in hospitals. J Hosp Med. 2006;1:21-28.
15. Morrison RS, et al. The growth of palliative care programs in United States hospitals. J Pall Med. 2006; 8 (6):1127-1133.

Get a Job!

SHM Launches the first-ever career Web site exclusively for hospitalists

By Jeannette Wick

Job boards—Internet sites designed to allow employers and prospective employees to find each other electronically—are among the most active Internet sites. For many job seekers Monster.com, CareerBuilder.com, and Indeed.com (among others) have become essential job search tools. Until now, however, no site has catered to healthcare professionals in general—much less to hospitalists in particular.

Thanks to the new SHM Career Center (http://hospitalmedicine.org/careercenter), though, things are about to change. The Career Center is part of a comprehensive, “cradle-to-grave” approach SHM is taking to assist hospital medicine professionals in their career development pursuits. The site offers numerous advantages over traditional job-hunting tools, such as classified advertisements, personal contacts, and randomly mailing resumes to interesting employers—advantages such as the ability to post your resume in a searchable database, a database of open positions across North America that you can search using a variety of variables and the opportunity to receive a notification when a job that matches your criteria is posted online.

 

The Career Center also represents an improvement over general job boards because the pool of positions offered and solicited on the site is restricted to those only for hospital medicine professionals. The site is free for all, although SHM members are able to take advantage of certain “members-only” functionality (resume posting, e-mail notification of new job postings). “Career opportunists,” or hospitalists who are gainfully employed but constantly curious about what else is available, will enjoy this site, too.

The Way it Works

SHM’s Career Center matches applicants and jobs using search features that allow applicants to tailor their search. As an applicant, you enter your job preferences as you would when searching for an article in PubMed or when looking online for a board-certified specialist in a specific geographic region when referring a patient. The boxes prompt you to provide the minimum information necessary for an acceptable search. For example, you need to provide geographical preferences, the type of position you’re looking for, and the specialty area you’re interested in to best tailor your search.

Visitors can browse all jobs by specialty or state—or view the complete list of jobs. The advanced search option augments the specialty and state fields with the ability to specify keywords (see “Hospitalists and Keywords,” p. 10), specialty, employment type (full time, moonlighting, and so on), and the announcement opening date. (The latter is important to applicants who believe older announcements raise a red flag indicating conditions that make it unattractive to candidates.)

The advanced search option also allows you to look at job summaries with the results. So instead of receiving a simple list of the job title, the location, and the announcement date, the summary includes a short description of the position. But visitor beware: You have to click a box to make this happen. Otherwise, your search will create a simple list of jobs, and clicking on any individual job will bring up the job summary. The information is accessible either way.

Get Started

Most job seekers will find the site quite easy to navigate, although a few may be impeded by cookies. (For more information, see “Got Cookies,” p. 10.) The FAQ area is a site strength and will help you eliminate hurdles, from inability to navigate the site, to figuring out how to be notified electronically when new jobs are added.

Once you enter your search criteria, a list of jobs displays. Then click on a specific job to open another page describing the position in great detail. After seeing the array of positions available, SHM non-members are likely to join the society just to have access to the full functionality of the Career Center.

Your next step is to create an account; doing so allows you to apply for positions with just a click. Once you establish an account (a process that takes just a few minutes), click on “Edit My Profile.” In this area, you’ll establish your profile.

 

Meat and Potatoes: Post Your Resume

The Career Center’s features are state-of-the-art. You can create a resume and a cover letter. To post your resume in “My Account,” for example, select “Post My Resume,” then “Document Management,” and then “Resume.” You’ll need to open a plain text version (no bold, underlining, italics, or bullets) of your current resume on your computer, and then copy your resume to the clipboard.

Never done this before? Here again, you can open a guidance window or a printable FAQ to walk you through the process. Two minor system limitations appear here: You must click a box to make the text wrap automatically, and the site has no spell-check function. You have to spell check your cover letter and resume before you copy and paste. If you edit your text at any time while in the Career Center boxes, then be sure to proofread to ensure you haven’t introduced any errors. After you create your resume, you can open a text version (a file that ends in the suffix .txt) to see how employers will view it.

In the past, hospital medicine applicants could stand out with a well-formatted resume on quality paper. Online documents force every applicant’s information into the same mold, and this often concerns applicants. Will a skilled, tri-lingual, well-published hospitalist look like every other applicant when an employer is looking at a simple text version of your resume?

The Career Center allows you to upload up to three formatted documents that can be attached to applications. If you are unable to upload your documents, you may e-mail them to the site, which will then attach them to your account. Some applicants find it useful to have two specific types of resumes on hand: a traditional reverse chronological resume that emphasizes experience, and a less structured functional resume that describes transferable skills.

Depending on your computer savvy, the time it takes to set up your account and load your resume will vary. Hospitalists with robust skills may be able to load a resume in fewer than 30 minutes, but it may take longer for others. Regardless, the return on investment is large because the information you enter will form the foundation of your materials that a perspective employer will review. Once your resume is loaded, applying for a position only requires a few clicks.

 

Benefits That Make Your Search Sizzle

If you are an SHM member, the “Job Agent” functionality allows you to receive weekly updates of new jobs added that match your search criteria. (Note: You can join SHM online through the Career Center or by visiting www.joinshm.org) This function is located in your account. It allows you to specify the date you would like to stop receiving notification e-mails. Your account also tracks applications submitted.

After you log in, click “Job Applications” to display any jobs you have applied for and the date that the application was submitted. When a job posting expires (according to a pre-established date set by the employer) a strikethrough line will appear through the job application. Applications remain in your account for 90 days from the submission date. Clicking on the “Apply for this Job” icon opens a new screen, and it allows applicants to edit applications even after you’ve sent it and until the job posting closes. Once the job posting is closed, no application changes can be made.

Employers post their vacancies for 30 days at a time, and they can select packages that include print advertisements in The Hospitalist and/or the Journal of Hospital Medicine. Approximately 85% of employers who advertise in print media also advertise on the Career Center, although a few advertise only on the Career Center. To cover your bases, look in all three places.

Just as some applicants prefer anonymity, some companies choose to list their ads confidentially. In these cases, you will submit your online application, and the employer will contact you via the system with more information if you are a good match.

Employer responses will be forwarded to your e-mail account through the Career Center. Once you begin talking with a prospective employer, it is up to you to use good research and interview skills to ensure that this is indeed a good match. When you find a position, you can remove your resume from circulation. Or, you can store it in the Career Center database for future opportunities by clicking “No, do not post my resume.”

Alternatively, you can remove your information from the database permanently: Go to “My Account” and select “Delete Account.”

What the Future Holds

SHM’s information services team will keep tabs on the recently launched SHM Career Center Web site and invites user feedback—specifically any demographic information that will help them build the most practical, useful career site for hospitalists.

With the average age of a hospitalist about 37, SHM expects that visitors and users to comprise a youthful, computer savvy group. Eventually, SHM wants to expand the site so it tells you more than just what jobs are available (e.g., how to create a resume, interview techniques, and how to build desirable hospital medicine skill sets). They will also track how many employer-employee matches are made using the Career Center.

Conclusion

When unemployment is low, as it most certainly is for hospitalists, leverage rests with job seekers, not employers. While employers are looking for talent and availability, career opportunists crave convenience. The SHM Career Center represents the most comprehensive collection of hospitalist opportunities available on the Internet.

Users will find site navigation easy, and prompts and cues offered by the site designers clear and accurate. Traffic on the site is expected to grow quickly as it becomes what SHM hopes is the most indispensable tool for hospitalists conducting job searches.TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

Each year a new team of SHM officers is elected to lend their wisdom, time, experience, and skills in a collaborative effort to help manage the business of our organization, drive new initiatives, and support the society’s mission. At this year’s annual meeting in Washington, D.C., we again witnessed that familiar changing of the guard with the following inductions:

• President Mary Jo Gorman, MD, MBA;
• President-Elect Russell Holman, MD;
• Treasurer Patrick Cawley, MD; and
• Secretary Jack Percelay, MD, MPH.

“Hospitalists are squarely in the spotlight today on key issues affecting patient care, quality of hospital care, hospital leadership, and other concerns. So it is important that we have a strong, hands-on leadership team that is committed to continuing the positive momentum SHM has generated for hospitalists,” says Larry Wellikson, MD, FACP, CEO of SHM. “I couldn’t be more thrilled with our slate of newly appointed officers. Time and again through the years Mary Jo, Rusty, Pat, and Jack have proven that they are active participants, and that they are leaders who will rise to the occasion to help us meet our objectives.”

Dr. Gorman, a charter member of SHM, has been a practicing hospitalist since 1997, when she founded the first hospitalist practice in St. Louis. In early 1999, her group merged into IPC—The Hospitalist Company and grew to become the dominant hospitalist group in the city. In 2001, Dr. Gorman was promoted to vice-president of medical affairs for IPC, responsible for the design and implementation of company-wide programs involving business development, recruitment, physician training, and operations in all of IPC’s markets. In 2003, she was named chief medical officer and today works with more than 300 physicians nationwide to develop programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and clinical studies.

A cum laude graduate of St. Louis University, Dr. Gorman earned a BA in Chemistry/Biology in 1981, then went on to earn her MD in 1984 from Southern Illinois University School of Medicine in Springfield. In 1996, she earned a MBA from Washington University, Olin School of Business, in St. Louis.

SHM’s new President-Elect Dr. Holman is senior vice president and national medical director for Cogent Healthcare, an organization that manages hospital medicine programs throughout the country. He is responsible for program implementation and management, quality systems reporting and auditing, physician leadership development, and data systems integration. Formerly, Dr. Holman was the medical director of Hospital Services for HealthPartners Medical Group & Clinics, part of HealthPartners, Inc. in Minnesota. There he also was the founder and director of the HPMG Fellowship Program in Hospital Medicine.

A long-time member of SHM, Dr. Holman served on the Board of Directors as treasurer from 2004-2005. He was previously chair of the Leadership Development Committee, chair of the Midwest Council, course director of the SHM Leadership Academy, and a member of the Public Policy Committee. In February 2006 he co-authored the “Update in Hospital Medicine,” which appeared in Annals of Internal Medicine. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine.

Through the years, Dr. Holman’s commitment to hospital medicine has helped produce nationally recognized standards in the areas of quality improvement activities, models of medical education, observation units, communication systems, compensation plans, case management, surgical co-management collaborations, and patient flow initiatives. Dr. Holman serves on two national editorial boards for medical publications and is currently co-authoring a comprehensive textbook and electronic decision support tool in hospital medicine.

 

Dr. Holman earned his MD from Washington University School of Medicine in St. Louis and trained as a resident and chief medical resident at the University of Minnesota in Minneapolis.

New Treasurer Dr. Cawley is a hospitalist at the Medical University of South Carolina in Charleston, where he currently serves as interim executive medical director of MUSC Medical Center. He previously served as the chief of the Section of Hospital Medicine, vice chairman of clinical affairs in the Department of Medicine, and associate executive medical director at MUSC Medical Center.

A charter member of SHM, Dr. Cawley has served on numerous committees and was previously secretary of the Board for the 2004-2005 term. He has worked in both academic and nonacademic hospitals and has served as a consultant to numerous hospitals in the development of hospital medicine programs.

Dr. Cawley received his Bachelor of Science in 1988 from the University of Scranton (Pa.) and his MD from Georgetown University School of Medicine in Washington, D.C. He completed an internal medicine residency at Duke University in Durham, N.C. Later this year, he will complete his MBA from the University of Massachusetts-Amherst.

SHM’s new secretary is Dr. Percelay. He is director of Virtua Inpatient Pediatrics, a large pediatric hospital medicine group in Southern New Jersey with 14 full-time hospitalists covering two hospitals. Since 1991, Dr. Percelay has worked in a variety of community-based settings including the general pediatric ward, pediatric sub-specialty units, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and the emergency department.

A charter member of SHM and one of the nation’s first pediatric hospitalists, Dr. Percelay currently holds the Pediatric Seat on the SHM Board, in addition to serving on the Public Policy Committee and co-chairing the Pediatric Committee. He has been intimately involved in collaborative Pediatric hospital medicine projects such as the PRIS research network and the Denver 2005 and 2007 Pediatric Hospital Medicine conferences.

Dr. Percelay is also the founding chairperson and immediate past chair of the American Academy of Pediatrics Section on Hospital Medicine and co-authored the AAP policy statement on pediatric hospitalists. He completed his medical school and pediatric training at the University of California at San Francisco, along with an MPH at the University of California at Berkeley.

SHM congratulates these new officers and thanks our 2005 officers (Steve Pantilat, MD, president, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary) for their exemplary work.

Annual Meeting e-Community a Success

If the feedback from attendees at this year’s Annual Meeting was any indication, the inaugural launch of SHM’s Annual Meeting e-Community was a success.

Each year, SHM’s Annual Meeting provides an opportunity for hospital medicine professionals to network with colleagues and take advantage of more than 40 educational sessions during the course of three days.

While the location for the meeting changes regularly, there is a constant desire within the Annual Meeting planning committee (a group of volunteer members) to improve the attendee experience. The Annual Meeting e-Community (AMeC) was designed with that in mind.

The AMeC effectively extended the reach of the annual meeting both before and after the event. Since early April, attendees have been able to access the handouts for the presentations that were given at the event and network with colleagues thanks to dedicated discussion communities. There are also listings of exhibitors scheduled to be in attendance and general information about Washington, D.C., on the AMeC.

Because of the positive feedback received, the e-Community will stay online through early July, giving attendees the chance to download presentations from sessions that they didn’t attend and make contact with colleagues they met while in Washington, D.C.

 

Attendees appreciated the ability to access meeting materials prior to the event. “The Annual Meeting e-Community gave me a great opportunity to really plan out the sessions that I wanted to attend prior to the meeting,” says William Rifkin, MD, a hospitalist from the Yale School of Medicine.

According to Joy Wittnebert, AMeC project manager, the site was launched in response to feedback from past annual meetings. “Attendees have been consistently telling us that they want to be able to customize their experience and have more opportunities to network with colleagues before and after the event,” she says.

In the coming months, SHM staff will work with the Annual Meeting Committee to analyze additional feedback and begin making plans for the 2007 version of the site.

SHM Education Committee Launches 18-Month Strategic Plan

Helping our members and the hospital medicine community advance in professional growth and development has been on center stage as seen in the SHM Education Committee’s recent completion of an 18-month strategic plan. The plan is a framework designed to guide staff and volunteer leadership as they work to expand the society’s current slate of educational offerings. Inherent in the framework’s design is a focus on taking advantage of the myriad new channels that have come online for delivering educational content.

The plan is rooted primarily in the recently released Core Competencies in Hospital Medicine. The Core Competencies are a benchmark for the development of curricula within the hospital medicine specialty.

“One of the most exciting parts of this plan is its connection to the Core Competencies,” says Geri Barnes, SHM’s director of education and quality initiatives. “The connection means that this is one of the strongest educational plans that the society has put forward.”

A driving force in the creation of this plan was the committee’s desire to expand SHM’s educational offerings through a variety of technologic venues. “In the coming year, our educational offerings will truly become multi-dimensional,” says Scott Johnson, SHM’s director of information services. “As we expand into audio CDs, podcasts, and Web-based offerings, more hospitalists will be able to take advantage of these learning opportunities, which will have profound effects on the hospital medicine movement.”

With the education plan approved by SHM’s Board of Directors at its recent meeting, the Education Committee, chaired by Preetha Basaviah, MD, from Stanford University, will turn its attention to the first stage of implementation—a complete needs analysis. Some research has already taken place as part of SHM’s ongoing internal quality improvement processes.

“The key to the success of our plan is that we will be integrating feedback from hospitalists throughout North America as we move forward,” says Dr. Basaviah. “Ultimately, this kind of communication will ensure that we reach our primary goal: to provide tools and resources that help hospital medicine professionals improve the quality of care that they provide.”

Stay tuned to The Hospitalist for updates on the committee’s progress and an advanced look at new educational products.

Palliative Care: a Core Competency for Hospitalists

By Theresa Kristopaitis, MD, with input from Howard Epstein, MD, and the SHM Palliative Care Task Force

Palliative care is focused on the relief of suffering and support for the best quality of life for patients facing serious, life-threatening, or advanced illness, as well as their families. Palliative care is a general approach to healthcare that should be routinely integrated with disease modifying therapies. It is also a growing practice specialty for appropriately trained healthcare professionals dedicating their practice to the delivery of palliative care services.1

 

Optimally palliative care is delivered through an interdisciplinary team consisting of physicians, nurses, chaplains, social workers, pharmacists, as well as other disciplines as patient/family needs warrant. Models of palliative care delivery include hospital-based inpatient consultation services, inpatient palliative care units, outpatient and home-based consultation services, and ambulatory clinics. Hospitalists are ideally positioned to start inpatient palliative care services and reap the professional and institutional benefits that palliative care offers. Tools to develop a program can be obtained through the Center to Advance Palliative Care (www.capc.org).

A Core Competency

The skills gained from developing expertise in palliative care are indispensable to hospitalists—even if they don’t formally work with a palliative care team. Palliative care itself is identified as a healthcare systems core competency of hospital medicine.2 In addition, other hospital medicine competencies overlap with those key to palliative care: pain management, care of the elderly patient and vulnerable populations, communication, hospitalist as consultant, team approach and multidisciplinary care, transitions of care, and medical ethics.3 For some of the most challenging, yet common, inpatient clinical scenarios, palliative care and hospital practice can become indistinguishable.

Inpatient Scenarios: How Can Palliative Care Help?

Scenario 1: A patient on chronic long-acting opiate therapy is admitted to the hospital with complaints of pain, nausea, and vomiting.

The appropriate assessment and management of pain is a patient’s right and an institution’s responsibility, yet it is often inadequate.4 Many barriers to effective pain management have been identified, including limited physician undergraduate and graduate training.4,5 A fundamental goal of palliative care is pain relief. In turn, expertise in the pathophysiology of pain and safe prescribing of opioid, non-opioid, and adjuvant analgesics is critical for palliative care physicians. Palliative care training and resources focus on principles of analgesic pharmacology, equianalgesia, changing routes of administration, control of continuous and breakthrough pain, opioid rotation, and adverse effects of analgesics. A comprehensive introduction to the fundamentals of pain management can be obtained via Education on Palliative and End of Life Care (www.epec.net.) Pain Management Module.

Non-pain symptoms can be as troubling for patients with advanced illness as pain. The formal assessment, reassessment, and management of common symptoms, including nausea, vomiting, dyspnea, constipation, fatigue, and delirium, are a primary domain of palliative medicine. Nausea and vomiting, for example, can become a demoralizing symptom complex. Stimuli to the vomiting center can arise from the cerebral cortex, vestibular apparatus, chemoreceptor zone, and gastrointestinal tract resulting in a broad etiologic differential diagnosis.

With a solid understanding of its pathogenesis and pharmacologic and non-pharmacologic therapeutic principles, nausea and vomiting can be treated in the vast majority of patients. Multiple agents addressing multiple mechanisms may be required. Even the nausea associated with complete bowel obstruction often can be successfully palliated, without the use of nasogastric tubes or surgery.6 The End of Life/Palliative Education Resource Center (www.eperc.mcw.edu) is one of many resources with tools to improve a hospitalist’s evaluation and treatment of non-pain physical symptoms.

Scenario 2: A patient with advanced heart failure and his family are overwhelmed by differing consultant opinions on the appropriateness of implantable cardioverter defibrillator (ICD) insertion.

Effective communication with patients is a core responsibility of both hospitalists and palliative care physicians. A complementary—and at times challenging—skill is the ability to promote communication and consensus about care among multiple specialist consultants. Ripamonti and colleagues write, “Almost invariably, the act of communication is an important part of therapy: Occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”6

 

The American Academy of Hospice and Palliative Medicine UNIPAC series is a resource for physicians to hone their general communication skills, as well as those more specific to palliative care, such as sharing news (often bad) with patients and families and engaging in therapeutic dialogue.8

Palliative care begins with establishing the goals of care with a patient.9 All physicians bring great value to patient care when they are skilled at negotiating goals of care. There are numerous possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. Ideally, goals of care should be discussed with patients and families as early as possible in the course of a serious, life-threatening illness. Establishing realistic and attainable goals of care assumes increased importance in the setting of advanced disease, where treatments intended to prolong life may become more burdensome than beneficial.9

As the reader may have experienced, too often these discussions have not taken place or are held late in the trajectory of illness, such as when patients are hospitalized for severe progressive disease or are facing imminent death.10 In the scenario of potential ICD insertion, conversations with patients to clarify device-specific goals are best accomplished before they are placed and in the context of a broader discussion of the patient’s general medical condition and overall goals for care.11 This type of discussion ultimately improves the informed consent process for ICDs and other technologies. ICD recipients should be guided to periodically revisit their goals, particularly when their health status significantly changes.11 Unlike for initial ICD placement, there are no guidelines for disabling already implanted ICDs. The opportunity to discuss this issue with a patient before a crisis or before they lose decision-making capacity is frequently lost and occurs all too often at life’s end.12

Scenario 3: An elderly debilitated woman with advanced cervical cancer has been hospitalized six times in the past two months. She is cared for at home. Her family is tired but they are doing “the best they can.” She is brought to the emergency department again with weakness.

Effective implementation of care management strategies for patients with life-threatening and advanced disease requires assessment of their physical, social, emotional, and spiritual concerns.1 Similarly, family caregivers have their own—often unvoiced—biopsychosocial stressors.13 Physicians directing patient care must appreciate the significance of these multiple issues, even if they are not comfortable or are ill-equipped to handle them on their own. The power of the interdisciplinary palliative care model is that team members evaluate the patient from different perspectives and pool their expertise in addressing the complex needs of their patients and families.8

In some multidisciplinary models, the onus may lie on the physician to recognize the patient and family needs and mobilize the appropriate resources. Coordination of care at home for patients in the later stages of chronic illness may seem daunting during hospital stays. However, by employing measures utilized by palliative care teams, such as reviewing the goals of care, introducing community resources to help patients and families manage at home, providing anticipatory grief and bereavement support, and considering hospice referral, discharge planning and transitions in care can be much more sustainable.14 With these interventions, patients, families, physicians, and hospitals all benefit.

Conclusion

Hospital-based palliative care programs are growing exponentially.15 Hospitalists are in a unique position to continue their development. Even if the time or circumstances are not yet right for you to become a part of a formal palliative care program, there are daily opportunities to reap rewards from the knowledge, attitudes, and skills that palliative care training offers.

 

References

1. National Consensus Project for Quality Palliative Care: The development of practice guidelines 2004. Available at www.nationalconsensusproject.org. Last accessed April 28, 2006.
2. Pistoria MJ, Amin AN, Dressler DD, et al. The core competencies in hospital medicine. J Hosp Med. 2006;1:2(S1).
3. American Board of Hospice and Palliative Medicine. Available at www.abhpm.org. Last accessed April 28, 2006.
4. Phillips DM. JCAHO pain management standards unveiled. JAMA. 2000;284:428-429.
5. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685-695.
6. Ripamonti C, De Conno F, Ventafridda V, et al. Management of bowel obstruction in advanced and terminal cancer patients. Ann Oncol. 1993 Jan;4(1):15-21.
7. Buckman R. Communication in palliative care: a practical guide. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford Community Press; 1993:47-61.
8. Storey P, Knight CF. UNIPAC five—caring for the terminally ill—communication and the physician’s role in the interdisciplinary team. In: Hospice/Palliative Care Training for Physicians—A Self Study Program. New York: Mary Ann Liebert; 2003:1-147.
9. Morrison RS, Meier DE. Palliative care. NEJM. 2004;350:2582-2590.
10. Quill TE. Initiating end of life discussion with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284:2502-2507.
11. Berger, JT. The ethics of deactivating implanted cardioverter defibrillators. Ann Intern Med. 2005;142:631-634.
12. Goldstein NE, Lampert R, Bradely E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141:835-838.
13. Levine C. The loneliness of the long-term caregiver. NEJM. 1999;340:1587-1590.
14. Meier D. Palliative care in hospitals. J Hosp Med. 2006;1:21-28.
15. Morrison RS, et al. The growth of palliative care programs in United States hospitals. J Pall Med. 2006; 8 (6):1127-1133.

Get a Job!

SHM Launches the first-ever career Web site exclusively for hospitalists

By Jeannette Wick

Job boards—Internet sites designed to allow employers and prospective employees to find each other electronically—are among the most active Internet sites. For many job seekers Monster.com, CareerBuilder.com, and Indeed.com (among others) have become essential job search tools. Until now, however, no site has catered to healthcare professionals in general—much less to hospitalists in particular.

Thanks to the new SHM Career Center (http://hospitalmedicine.org/careercenter), though, things are about to change. The Career Center is part of a comprehensive, “cradle-to-grave” approach SHM is taking to assist hospital medicine professionals in their career development pursuits. The site offers numerous advantages over traditional job-hunting tools, such as classified advertisements, personal contacts, and randomly mailing resumes to interesting employers—advantages such as the ability to post your resume in a searchable database, a database of open positions across North America that you can search using a variety of variables and the opportunity to receive a notification when a job that matches your criteria is posted online.

 

The Career Center also represents an improvement over general job boards because the pool of positions offered and solicited on the site is restricted to those only for hospital medicine professionals. The site is free for all, although SHM members are able to take advantage of certain “members-only” functionality (resume posting, e-mail notification of new job postings). “Career opportunists,” or hospitalists who are gainfully employed but constantly curious about what else is available, will enjoy this site, too.

The Way it Works

SHM’s Career Center matches applicants and jobs using search features that allow applicants to tailor their search. As an applicant, you enter your job preferences as you would when searching for an article in PubMed or when looking online for a board-certified specialist in a specific geographic region when referring a patient. The boxes prompt you to provide the minimum information necessary for an acceptable search. For example, you need to provide geographical preferences, the type of position you’re looking for, and the specialty area you’re interested in to best tailor your search.

Visitors can browse all jobs by specialty or state—or view the complete list of jobs. The advanced search option augments the specialty and state fields with the ability to specify keywords (see “Hospitalists and Keywords,” p. 10), specialty, employment type (full time, moonlighting, and so on), and the announcement opening date. (The latter is important to applicants who believe older announcements raise a red flag indicating conditions that make it unattractive to candidates.)

The advanced search option also allows you to look at job summaries with the results. So instead of receiving a simple list of the job title, the location, and the announcement date, the summary includes a short description of the position. But visitor beware: You have to click a box to make this happen. Otherwise, your search will create a simple list of jobs, and clicking on any individual job will bring up the job summary. The information is accessible either way.

Get Started

Most job seekers will find the site quite easy to navigate, although a few may be impeded by cookies. (For more information, see “Got Cookies,” p. 10.) The FAQ area is a site strength and will help you eliminate hurdles, from inability to navigate the site, to figuring out how to be notified electronically when new jobs are added.

Once you enter your search criteria, a list of jobs displays. Then click on a specific job to open another page describing the position in great detail. After seeing the array of positions available, SHM non-members are likely to join the society just to have access to the full functionality of the Career Center.

Your next step is to create an account; doing so allows you to apply for positions with just a click. Once you establish an account (a process that takes just a few minutes), click on “Edit My Profile.” In this area, you’ll establish your profile.

 

Meat and Potatoes: Post Your Resume

The Career Center’s features are state-of-the-art. You can create a resume and a cover letter. To post your resume in “My Account,” for example, select “Post My Resume,” then “Document Management,” and then “Resume.” You’ll need to open a plain text version (no bold, underlining, italics, or bullets) of your current resume on your computer, and then copy your resume to the clipboard.

Never done this before? Here again, you can open a guidance window or a printable FAQ to walk you through the process. Two minor system limitations appear here: You must click a box to make the text wrap automatically, and the site has no spell-check function. You have to spell check your cover letter and resume before you copy and paste. If you edit your text at any time while in the Career Center boxes, then be sure to proofread to ensure you haven’t introduced any errors. After you create your resume, you can open a text version (a file that ends in the suffix .txt) to see how employers will view it.

In the past, hospital medicine applicants could stand out with a well-formatted resume on quality paper. Online documents force every applicant’s information into the same mold, and this often concerns applicants. Will a skilled, tri-lingual, well-published hospitalist look like every other applicant when an employer is looking at a simple text version of your resume?

The Career Center allows you to upload up to three formatted documents that can be attached to applications. If you are unable to upload your documents, you may e-mail them to the site, which will then attach them to your account. Some applicants find it useful to have two specific types of resumes on hand: a traditional reverse chronological resume that emphasizes experience, and a less structured functional resume that describes transferable skills.

Depending on your computer savvy, the time it takes to set up your account and load your resume will vary. Hospitalists with robust skills may be able to load a resume in fewer than 30 minutes, but it may take longer for others. Regardless, the return on investment is large because the information you enter will form the foundation of your materials that a perspective employer will review. Once your resume is loaded, applying for a position only requires a few clicks.

 

Benefits That Make Your Search Sizzle

If you are an SHM member, the “Job Agent” functionality allows you to receive weekly updates of new jobs added that match your search criteria. (Note: You can join SHM online through the Career Center or by visiting www.joinshm.org) This function is located in your account. It allows you to specify the date you would like to stop receiving notification e-mails. Your account also tracks applications submitted.

After you log in, click “Job Applications” to display any jobs you have applied for and the date that the application was submitted. When a job posting expires (according to a pre-established date set by the employer) a strikethrough line will appear through the job application. Applications remain in your account for 90 days from the submission date. Clicking on the “Apply for this Job” icon opens a new screen, and it allows applicants to edit applications even after you’ve sent it and until the job posting closes. Once the job posting is closed, no application changes can be made.

Employers post their vacancies for 30 days at a time, and they can select packages that include print advertisements in The Hospitalist and/or the Journal of Hospital Medicine. Approximately 85% of employers who advertise in print media also advertise on the Career Center, although a few advertise only on the Career Center. To cover your bases, look in all three places.

Just as some applicants prefer anonymity, some companies choose to list their ads confidentially. In these cases, you will submit your online application, and the employer will contact you via the system with more information if you are a good match.

Employer responses will be forwarded to your e-mail account through the Career Center. Once you begin talking with a prospective employer, it is up to you to use good research and interview skills to ensure that this is indeed a good match. When you find a position, you can remove your resume from circulation. Or, you can store it in the Career Center database for future opportunities by clicking “No, do not post my resume.”

Alternatively, you can remove your information from the database permanently: Go to “My Account” and select “Delete Account.”

What the Future Holds

SHM’s information services team will keep tabs on the recently launched SHM Career Center Web site and invites user feedback—specifically any demographic information that will help them build the most practical, useful career site for hospitalists.

With the average age of a hospitalist about 37, SHM expects that visitors and users to comprise a youthful, computer savvy group. Eventually, SHM wants to expand the site so it tells you more than just what jobs are available (e.g., how to create a resume, interview techniques, and how to build desirable hospital medicine skill sets). They will also track how many employer-employee matches are made using the Career Center.

Conclusion

When unemployment is low, as it most certainly is for hospitalists, leverage rests with job seekers, not employers. While employers are looking for talent and availability, career opportunists crave convenience. The SHM Career Center represents the most comprehensive collection of hospitalist opportunities available on the Internet.

Users will find site navigation easy, and prompts and cues offered by the site designers clear and accurate. Traffic on the site is expected to grow quickly as it becomes what SHM hopes is the most indispensable tool for hospitalists conducting job searches.TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

Each year a new team of SHM officers is elected to lend their wisdom, time, experience, and skills in a collaborative effort to help manage the business of our organization, drive new initiatives, and support the society’s mission. At this year’s annual meeting in Washington, D.C., we again witnessed that familiar changing of the guard with the following inductions:

• President Mary Jo Gorman, MD, MBA;
• President-Elect Russell Holman, MD;
• Treasurer Patrick Cawley, MD; and
• Secretary Jack Percelay, MD, MPH.

“Hospitalists are squarely in the spotlight today on key issues affecting patient care, quality of hospital care, hospital leadership, and other concerns. So it is important that we have a strong, hands-on leadership team that is committed to continuing the positive momentum SHM has generated for hospitalists,” says Larry Wellikson, MD, FACP, CEO of SHM. “I couldn’t be more thrilled with our slate of newly appointed officers. Time and again through the years Mary Jo, Rusty, Pat, and Jack have proven that they are active participants, and that they are leaders who will rise to the occasion to help us meet our objectives.”

Dr. Gorman, a charter member of SHM, has been a practicing hospitalist since 1997, when she founded the first hospitalist practice in St. Louis. In early 1999, her group merged into IPC—The Hospitalist Company and grew to become the dominant hospitalist group in the city. In 2001, Dr. Gorman was promoted to vice-president of medical affairs for IPC, responsible for the design and implementation of company-wide programs involving business development, recruitment, physician training, and operations in all of IPC’s markets. In 2003, she was named chief medical officer and today works with more than 300 physicians nationwide to develop programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and clinical studies.

A cum laude graduate of St. Louis University, Dr. Gorman earned a BA in Chemistry/Biology in 1981, then went on to earn her MD in 1984 from Southern Illinois University School of Medicine in Springfield. In 1996, she earned a MBA from Washington University, Olin School of Business, in St. Louis.

SHM’s new President-Elect Dr. Holman is senior vice president and national medical director for Cogent Healthcare, an organization that manages hospital medicine programs throughout the country. He is responsible for program implementation and management, quality systems reporting and auditing, physician leadership development, and data systems integration. Formerly, Dr. Holman was the medical director of Hospital Services for HealthPartners Medical Group & Clinics, part of HealthPartners, Inc. in Minnesota. There he also was the founder and director of the HPMG Fellowship Program in Hospital Medicine.

A long-time member of SHM, Dr. Holman served on the Board of Directors as treasurer from 2004-2005. He was previously chair of the Leadership Development Committee, chair of the Midwest Council, course director of the SHM Leadership Academy, and a member of the Public Policy Committee. In February 2006 he co-authored the “Update in Hospital Medicine,” which appeared in Annals of Internal Medicine. In 2002, he received the SHM Award for Outstanding Service in Hospital Medicine.

Through the years, Dr. Holman’s commitment to hospital medicine has helped produce nationally recognized standards in the areas of quality improvement activities, models of medical education, observation units, communication systems, compensation plans, case management, surgical co-management collaborations, and patient flow initiatives. Dr. Holman serves on two national editorial boards for medical publications and is currently co-authoring a comprehensive textbook and electronic decision support tool in hospital medicine.

 

Dr. Holman earned his MD from Washington University School of Medicine in St. Louis and trained as a resident and chief medical resident at the University of Minnesota in Minneapolis.

New Treasurer Dr. Cawley is a hospitalist at the Medical University of South Carolina in Charleston, where he currently serves as interim executive medical director of MUSC Medical Center. He previously served as the chief of the Section of Hospital Medicine, vice chairman of clinical affairs in the Department of Medicine, and associate executive medical director at MUSC Medical Center.

A charter member of SHM, Dr. Cawley has served on numerous committees and was previously secretary of the Board for the 2004-2005 term. He has worked in both academic and nonacademic hospitals and has served as a consultant to numerous hospitals in the development of hospital medicine programs.

Dr. Cawley received his Bachelor of Science in 1988 from the University of Scranton (Pa.) and his MD from Georgetown University School of Medicine in Washington, D.C. He completed an internal medicine residency at Duke University in Durham, N.C. Later this year, he will complete his MBA from the University of Massachusetts-Amherst.

SHM’s new secretary is Dr. Percelay. He is director of Virtua Inpatient Pediatrics, a large pediatric hospital medicine group in Southern New Jersey with 14 full-time hospitalists covering two hospitals. Since 1991, Dr. Percelay has worked in a variety of community-based settings including the general pediatric ward, pediatric sub-specialty units, pediatric intensive care unit (PICU), neonatal intensive care unit (NICU), and the emergency department.

A charter member of SHM and one of the nation’s first pediatric hospitalists, Dr. Percelay currently holds the Pediatric Seat on the SHM Board, in addition to serving on the Public Policy Committee and co-chairing the Pediatric Committee. He has been intimately involved in collaborative Pediatric hospital medicine projects such as the PRIS research network and the Denver 2005 and 2007 Pediatric Hospital Medicine conferences.

Dr. Percelay is also the founding chairperson and immediate past chair of the American Academy of Pediatrics Section on Hospital Medicine and co-authored the AAP policy statement on pediatric hospitalists. He completed his medical school and pediatric training at the University of California at San Francisco, along with an MPH at the University of California at Berkeley.

SHM congratulates these new officers and thanks our 2005 officers (Steve Pantilat, MD, president, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary) for their exemplary work.

Annual Meeting e-Community a Success

If the feedback from attendees at this year’s Annual Meeting was any indication, the inaugural launch of SHM’s Annual Meeting e-Community was a success.

Each year, SHM’s Annual Meeting provides an opportunity for hospital medicine professionals to network with colleagues and take advantage of more than 40 educational sessions during the course of three days.

While the location for the meeting changes regularly, there is a constant desire within the Annual Meeting planning committee (a group of volunteer members) to improve the attendee experience. The Annual Meeting e-Community (AMeC) was designed with that in mind.

The AMeC effectively extended the reach of the annual meeting both before and after the event. Since early April, attendees have been able to access the handouts for the presentations that were given at the event and network with colleagues thanks to dedicated discussion communities. There are also listings of exhibitors scheduled to be in attendance and general information about Washington, D.C., on the AMeC.

Because of the positive feedback received, the e-Community will stay online through early July, giving attendees the chance to download presentations from sessions that they didn’t attend and make contact with colleagues they met while in Washington, D.C.

 

Attendees appreciated the ability to access meeting materials prior to the event. “The Annual Meeting e-Community gave me a great opportunity to really plan out the sessions that I wanted to attend prior to the meeting,” says William Rifkin, MD, a hospitalist from the Yale School of Medicine.

According to Joy Wittnebert, AMeC project manager, the site was launched in response to feedback from past annual meetings. “Attendees have been consistently telling us that they want to be able to customize their experience and have more opportunities to network with colleagues before and after the event,” she says.

In the coming months, SHM staff will work with the Annual Meeting Committee to analyze additional feedback and begin making plans for the 2007 version of the site.

SHM Education Committee Launches 18-Month Strategic Plan

Helping our members and the hospital medicine community advance in professional growth and development has been on center stage as seen in the SHM Education Committee’s recent completion of an 18-month strategic plan. The plan is a framework designed to guide staff and volunteer leadership as they work to expand the society’s current slate of educational offerings. Inherent in the framework’s design is a focus on taking advantage of the myriad new channels that have come online for delivering educational content.

The plan is rooted primarily in the recently released Core Competencies in Hospital Medicine. The Core Competencies are a benchmark for the development of curricula within the hospital medicine specialty.

“One of the most exciting parts of this plan is its connection to the Core Competencies,” says Geri Barnes, SHM’s director of education and quality initiatives. “The connection means that this is one of the strongest educational plans that the society has put forward.”

A driving force in the creation of this plan was the committee’s desire to expand SHM’s educational offerings through a variety of technologic venues. “In the coming year, our educational offerings will truly become multi-dimensional,” says Scott Johnson, SHM’s director of information services. “As we expand into audio CDs, podcasts, and Web-based offerings, more hospitalists will be able to take advantage of these learning opportunities, which will have profound effects on the hospital medicine movement.”

With the education plan approved by SHM’s Board of Directors at its recent meeting, the Education Committee, chaired by Preetha Basaviah, MD, from Stanford University, will turn its attention to the first stage of implementation—a complete needs analysis. Some research has already taken place as part of SHM’s ongoing internal quality improvement processes.

“The key to the success of our plan is that we will be integrating feedback from hospitalists throughout North America as we move forward,” says Dr. Basaviah. “Ultimately, this kind of communication will ensure that we reach our primary goal: to provide tools and resources that help hospital medicine professionals improve the quality of care that they provide.”

Stay tuned to The Hospitalist for updates on the committee’s progress and an advanced look at new educational products.

Palliative Care: a Core Competency for Hospitalists

By Theresa Kristopaitis, MD, with input from Howard Epstein, MD, and the SHM Palliative Care Task Force

Palliative care is focused on the relief of suffering and support for the best quality of life for patients facing serious, life-threatening, or advanced illness, as well as their families. Palliative care is a general approach to healthcare that should be routinely integrated with disease modifying therapies. It is also a growing practice specialty for appropriately trained healthcare professionals dedicating their practice to the delivery of palliative care services.1

 

Optimally palliative care is delivered through an interdisciplinary team consisting of physicians, nurses, chaplains, social workers, pharmacists, as well as other disciplines as patient/family needs warrant. Models of palliative care delivery include hospital-based inpatient consultation services, inpatient palliative care units, outpatient and home-based consultation services, and ambulatory clinics. Hospitalists are ideally positioned to start inpatient palliative care services and reap the professional and institutional benefits that palliative care offers. Tools to develop a program can be obtained through the Center to Advance Palliative Care (www.capc.org).

A Core Competency

The skills gained from developing expertise in palliative care are indispensable to hospitalists—even if they don’t formally work with a palliative care team. Palliative care itself is identified as a healthcare systems core competency of hospital medicine.2 In addition, other hospital medicine competencies overlap with those key to palliative care: pain management, care of the elderly patient and vulnerable populations, communication, hospitalist as consultant, team approach and multidisciplinary care, transitions of care, and medical ethics.3 For some of the most challenging, yet common, inpatient clinical scenarios, palliative care and hospital practice can become indistinguishable.

Inpatient Scenarios: How Can Palliative Care Help?

Scenario 1: A patient on chronic long-acting opiate therapy is admitted to the hospital with complaints of pain, nausea, and vomiting.

The appropriate assessment and management of pain is a patient’s right and an institution’s responsibility, yet it is often inadequate.4 Many barriers to effective pain management have been identified, including limited physician undergraduate and graduate training.4,5 A fundamental goal of palliative care is pain relief. In turn, expertise in the pathophysiology of pain and safe prescribing of opioid, non-opioid, and adjuvant analgesics is critical for palliative care physicians. Palliative care training and resources focus on principles of analgesic pharmacology, equianalgesia, changing routes of administration, control of continuous and breakthrough pain, opioid rotation, and adverse effects of analgesics. A comprehensive introduction to the fundamentals of pain management can be obtained via Education on Palliative and End of Life Care (www.epec.net.) Pain Management Module.

Non-pain symptoms can be as troubling for patients with advanced illness as pain. The formal assessment, reassessment, and management of common symptoms, including nausea, vomiting, dyspnea, constipation, fatigue, and delirium, are a primary domain of palliative medicine. Nausea and vomiting, for example, can become a demoralizing symptom complex. Stimuli to the vomiting center can arise from the cerebral cortex, vestibular apparatus, chemoreceptor zone, and gastrointestinal tract resulting in a broad etiologic differential diagnosis.

With a solid understanding of its pathogenesis and pharmacologic and non-pharmacologic therapeutic principles, nausea and vomiting can be treated in the vast majority of patients. Multiple agents addressing multiple mechanisms may be required. Even the nausea associated with complete bowel obstruction often can be successfully palliated, without the use of nasogastric tubes or surgery.6 The End of Life/Palliative Education Resource Center (www.eperc.mcw.edu) is one of many resources with tools to improve a hospitalist’s evaluation and treatment of non-pain physical symptoms.

Scenario 2: A patient with advanced heart failure and his family are overwhelmed by differing consultant opinions on the appropriateness of implantable cardioverter defibrillator (ICD) insertion.

Effective communication with patients is a core responsibility of both hospitalists and palliative care physicians. A complementary—and at times challenging—skill is the ability to promote communication and consensus about care among multiple specialist consultants. Ripamonti and colleagues write, “Almost invariably, the act of communication is an important part of therapy: Occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”6

 

The American Academy of Hospice and Palliative Medicine UNIPAC series is a resource for physicians to hone their general communication skills, as well as those more specific to palliative care, such as sharing news (often bad) with patients and families and engaging in therapeutic dialogue.8

Palliative care begins with establishing the goals of care with a patient.9 All physicians bring great value to patient care when they are skilled at negotiating goals of care. There are numerous possible goals of care, from prevention, to cure, to prolongation of life, to achieving a good death. Ideally, goals of care should be discussed with patients and families as early as possible in the course of a serious, life-threatening illness. Establishing realistic and attainable goals of care assumes increased importance in the setting of advanced disease, where treatments intended to prolong life may become more burdensome than beneficial.9

As the reader may have experienced, too often these discussions have not taken place or are held late in the trajectory of illness, such as when patients are hospitalized for severe progressive disease or are facing imminent death.10 In the scenario of potential ICD insertion, conversations with patients to clarify device-specific goals are best accomplished before they are placed and in the context of a broader discussion of the patient’s general medical condition and overall goals for care.11 This type of discussion ultimately improves the informed consent process for ICDs and other technologies. ICD recipients should be guided to periodically revisit their goals, particularly when their health status significantly changes.11 Unlike for initial ICD placement, there are no guidelines for disabling already implanted ICDs. The opportunity to discuss this issue with a patient before a crisis or before they lose decision-making capacity is frequently lost and occurs all too often at life’s end.12

Scenario 3: An elderly debilitated woman with advanced cervical cancer has been hospitalized six times in the past two months. She is cared for at home. Her family is tired but they are doing “the best they can.” She is brought to the emergency department again with weakness.

Effective implementation of care management strategies for patients with life-threatening and advanced disease requires assessment of their physical, social, emotional, and spiritual concerns.1 Similarly, family caregivers have their own—often unvoiced—biopsychosocial stressors.13 Physicians directing patient care must appreciate the significance of these multiple issues, even if they are not comfortable or are ill-equipped to handle them on their own. The power of the interdisciplinary palliative care model is that team members evaluate the patient from different perspectives and pool their expertise in addressing the complex needs of their patients and families.8

In some multidisciplinary models, the onus may lie on the physician to recognize the patient and family needs and mobilize the appropriate resources. Coordination of care at home for patients in the later stages of chronic illness may seem daunting during hospital stays. However, by employing measures utilized by palliative care teams, such as reviewing the goals of care, introducing community resources to help patients and families manage at home, providing anticipatory grief and bereavement support, and considering hospice referral, discharge planning and transitions in care can be much more sustainable.14 With these interventions, patients, families, physicians, and hospitals all benefit.

Conclusion

Hospital-based palliative care programs are growing exponentially.15 Hospitalists are in a unique position to continue their development. Even if the time or circumstances are not yet right for you to become a part of a formal palliative care program, there are daily opportunities to reap rewards from the knowledge, attitudes, and skills that palliative care training offers.

 

References

1. National Consensus Project for Quality Palliative Care: The development of practice guidelines 2004. Available at www.nationalconsensusproject.org. Last accessed April 28, 2006.
2. Pistoria MJ, Amin AN, Dressler DD, et al. The core competencies in hospital medicine. J Hosp Med. 2006;1:2(S1).
3. American Board of Hospice and Palliative Medicine. Available at www.abhpm.org. Last accessed April 28, 2006.
4. Phillips DM. JCAHO pain management standards unveiled. JAMA. 2000;284:428-429.
5. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685-695.
6. Ripamonti C, De Conno F, Ventafridda V, et al. Management of bowel obstruction in advanced and terminal cancer patients. Ann Oncol. 1993 Jan;4(1):15-21.
7. Buckman R. Communication in palliative care: a practical guide. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford Community Press; 1993:47-61.
8. Storey P, Knight CF. UNIPAC five—caring for the terminally ill—communication and the physician’s role in the interdisciplinary team. In: Hospice/Palliative Care Training for Physicians—A Self Study Program. New York: Mary Ann Liebert; 2003:1-147.
9. Morrison RS, Meier DE. Palliative care. NEJM. 2004;350:2582-2590.
10. Quill TE. Initiating end of life discussion with seriously ill patients: addressing the “elephant in the room.” JAMA. 2000;284:2502-2507.
11. Berger, JT. The ethics of deactivating implanted cardioverter defibrillators. Ann Intern Med. 2005;142:631-634.
12. Goldstein NE, Lampert R, Bradely E, et al. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med. 2004;141:835-838.
13. Levine C. The loneliness of the long-term caregiver. NEJM. 1999;340:1587-1590.
14. Meier D. Palliative care in hospitals. J Hosp Med. 2006;1:21-28.
15. Morrison RS, et al. The growth of palliative care programs in United States hospitals. J Pall Med. 2006; 8 (6):1127-1133.

Get a Job!

SHM Launches the first-ever career Web site exclusively for hospitalists

By Jeannette Wick

Job boards—Internet sites designed to allow employers and prospective employees to find each other electronically—are among the most active Internet sites. For many job seekers Monster.com, CareerBuilder.com, and Indeed.com (among others) have become essential job search tools. Until now, however, no site has catered to healthcare professionals in general—much less to hospitalists in particular.

Thanks to the new SHM Career Center (http://hospitalmedicine.org/careercenter), though, things are about to change. The Career Center is part of a comprehensive, “cradle-to-grave” approach SHM is taking to assist hospital medicine professionals in their career development pursuits. The site offers numerous advantages over traditional job-hunting tools, such as classified advertisements, personal contacts, and randomly mailing resumes to interesting employers—advantages such as the ability to post your resume in a searchable database, a database of open positions across North America that you can search using a variety of variables and the opportunity to receive a notification when a job that matches your criteria is posted online.

 

The Career Center also represents an improvement over general job boards because the pool of positions offered and solicited on the site is restricted to those only for hospital medicine professionals. The site is free for all, although SHM members are able to take advantage of certain “members-only” functionality (resume posting, e-mail notification of new job postings). “Career opportunists,” or hospitalists who are gainfully employed but constantly curious about what else is available, will enjoy this site, too.

The Way it Works

SHM’s Career Center matches applicants and jobs using search features that allow applicants to tailor their search. As an applicant, you enter your job preferences as you would when searching for an article in PubMed or when looking online for a board-certified specialist in a specific geographic region when referring a patient. The boxes prompt you to provide the minimum information necessary for an acceptable search. For example, you need to provide geographical preferences, the type of position you’re looking for, and the specialty area you’re interested in to best tailor your search.

Visitors can browse all jobs by specialty or state—or view the complete list of jobs. The advanced search option augments the specialty and state fields with the ability to specify keywords (see “Hospitalists and Keywords,” p. 10), specialty, employment type (full time, moonlighting, and so on), and the announcement opening date. (The latter is important to applicants who believe older announcements raise a red flag indicating conditions that make it unattractive to candidates.)

The advanced search option also allows you to look at job summaries with the results. So instead of receiving a simple list of the job title, the location, and the announcement date, the summary includes a short description of the position. But visitor beware: You have to click a box to make this happen. Otherwise, your search will create a simple list of jobs, and clicking on any individual job will bring up the job summary. The information is accessible either way.

Get Started

Most job seekers will find the site quite easy to navigate, although a few may be impeded by cookies. (For more information, see “Got Cookies,” p. 10.) The FAQ area is a site strength and will help you eliminate hurdles, from inability to navigate the site, to figuring out how to be notified electronically when new jobs are added.

Once you enter your search criteria, a list of jobs displays. Then click on a specific job to open another page describing the position in great detail. After seeing the array of positions available, SHM non-members are likely to join the society just to have access to the full functionality of the Career Center.

Your next step is to create an account; doing so allows you to apply for positions with just a click. Once you establish an account (a process that takes just a few minutes), click on “Edit My Profile.” In this area, you’ll establish your profile.

 

Meat and Potatoes: Post Your Resume

The Career Center’s features are state-of-the-art. You can create a resume and a cover letter. To post your resume in “My Account,” for example, select “Post My Resume,” then “Document Management,” and then “Resume.” You’ll need to open a plain text version (no bold, underlining, italics, or bullets) of your current resume on your computer, and then copy your resume to the clipboard.

Never done this before? Here again, you can open a guidance window or a printable FAQ to walk you through the process. Two minor system limitations appear here: You must click a box to make the text wrap automatically, and the site has no spell-check function. You have to spell check your cover letter and resume before you copy and paste. If you edit your text at any time while in the Career Center boxes, then be sure to proofread to ensure you haven’t introduced any errors. After you create your resume, you can open a text version (a file that ends in the suffix .txt) to see how employers will view it.

In the past, hospital medicine applicants could stand out with a well-formatted resume on quality paper. Online documents force every applicant’s information into the same mold, and this often concerns applicants. Will a skilled, tri-lingual, well-published hospitalist look like every other applicant when an employer is looking at a simple text version of your resume?

The Career Center allows you to upload up to three formatted documents that can be attached to applications. If you are unable to upload your documents, you may e-mail them to the site, which will then attach them to your account. Some applicants find it useful to have two specific types of resumes on hand: a traditional reverse chronological resume that emphasizes experience, and a less structured functional resume that describes transferable skills.

Depending on your computer savvy, the time it takes to set up your account and load your resume will vary. Hospitalists with robust skills may be able to load a resume in fewer than 30 minutes, but it may take longer for others. Regardless, the return on investment is large because the information you enter will form the foundation of your materials that a perspective employer will review. Once your resume is loaded, applying for a position only requires a few clicks.

 

Benefits That Make Your Search Sizzle

If you are an SHM member, the “Job Agent” functionality allows you to receive weekly updates of new jobs added that match your search criteria. (Note: You can join SHM online through the Career Center or by visiting www.joinshm.org) This function is located in your account. It allows you to specify the date you would like to stop receiving notification e-mails. Your account also tracks applications submitted.

After you log in, click “Job Applications” to display any jobs you have applied for and the date that the application was submitted. When a job posting expires (according to a pre-established date set by the employer) a strikethrough line will appear through the job application. Applications remain in your account for 90 days from the submission date. Clicking on the “Apply for this Job” icon opens a new screen, and it allows applicants to edit applications even after you’ve sent it and until the job posting closes. Once the job posting is closed, no application changes can be made.

Employers post their vacancies for 30 days at a time, and they can select packages that include print advertisements in The Hospitalist and/or the Journal of Hospital Medicine. Approximately 85% of employers who advertise in print media also advertise on the Career Center, although a few advertise only on the Career Center. To cover your bases, look in all three places.

Just as some applicants prefer anonymity, some companies choose to list their ads confidentially. In these cases, you will submit your online application, and the employer will contact you via the system with more information if you are a good match.

Employer responses will be forwarded to your e-mail account through the Career Center. Once you begin talking with a prospective employer, it is up to you to use good research and interview skills to ensure that this is indeed a good match. When you find a position, you can remove your resume from circulation. Or, you can store it in the Career Center database for future opportunities by clicking “No, do not post my resume.”

Alternatively, you can remove your information from the database permanently: Go to “My Account” and select “Delete Account.”

What the Future Holds

SHM’s information services team will keep tabs on the recently launched SHM Career Center Web site and invites user feedback—specifically any demographic information that will help them build the most practical, useful career site for hospitalists.

With the average age of a hospitalist about 37, SHM expects that visitors and users to comprise a youthful, computer savvy group. Eventually, SHM wants to expand the site so it tells you more than just what jobs are available (e.g., how to create a resume, interview techniques, and how to build desirable hospital medicine skill sets). They will also track how many employer-employee matches are made using the Career Center.

Conclusion

When unemployment is low, as it most certainly is for hospitalists, leverage rests with job seekers, not employers. While employers are looking for talent and availability, career opportunists crave convenience. The SHM Career Center represents the most comprehensive collection of hospitalist opportunities available on the Internet.

Users will find site navigation easy, and prompts and cues offered by the site designers clear and accurate. Traffic on the site is expected to grow quickly as it becomes what SHM hopes is the most indispensable tool for hospitalists conducting job searches.TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

Man attempts suicide after telephone consultations

Kitsap County (WA) Superior Court

A 38-year-old man was hospitalized after a suicide attempt. He was diagnosed as having bipolar affective disorder and treated with lithium and olanzapine. Over the next 3 months a psychiatrist treated him, discontinued olanzapine and lithium, and started valproic acid.

Four months after the suicide attempt, the patient’s wife called the psychiatrist. The patient claims his wife told the psychiatrist he was having paranoid delusions similar to those he had experienced before the suicide attempt. The psychiatrist says the wife reported only that the patient was confused. The psychiatrist told her that her husband should resume taking olanzapine and report the results in 1 to 2 days.

Two days later, the psychiatrist received a voice mail from the patient’s wife, who reported that her husband had improved. The psychiatrist testified that he returned the call and was told that the patient was doing well. The patient denied that this call was made.

The next day, the patient concealed a knife in his briefcase, drove to a wooded area, and stabbed himself three times, lacerating his heart, lung, and diaphragm. He underwent surgery and survived.

In court, the patient argued that if the psychiatrist had evaluated him in person instead of over the telephone, the psychiatrist would have recommended hospitalization. He also alleged that the psychiatrist did not obtain informed consent before stopping olanzapine.

The psychiatrist argued that the patient gave informed consent to withdraw olanzapine and that the second suicide attempt was sudden, unpredictable, and impulsive.

• The jury decided for the defense.
  

Called-in prescription fails to prevent suicide

Unknown Massachusetts venue

A woman with a history of depression, anxiety, and difficulty following prescriptions attempted suicide and was hospitalized after she and her husband separated.

After discharge and under the care of a psychiatrist, the patient became dependent on lorazepam. When she tried to renew her lorazepam prescription but could not reach the psychiatrist, she called the pharmacy and attempted to impersonate the psychiatrist. The pharmacy did not fill the prescription and notified the psychiatrist.

The psychiatrist called the patient that evening and spoke with the patient and her minister, who was with her. The psychiatrist informed the minister that the medication would be delivered to the house if the minister paid for it, administered it to the patient, and saw her to bed. The minister agreed and followed the psychiatrist’s instructions when the medication arrived.

Later that night, the woman broke into the minister’s church and was apprehended by police. She was released after the minister assured police that the break-in was not a criminal matter.

At home, the patient called the psychiatrist again and left a voice mail. Phone records indicate that she stayed on the line for 5 minutes. The psychiatrist reported that he did not receive the message until the next day. By that time, the patient had hanged herself with a leather strap.

The patient’s family claimed that the church break-in was a new, risky behavior that warranted an in-person evaluation. The psychiatrist argued that the patient often called his office, that the tone of her message did not suggest an imminent suicide attempt, and that neither the minister nor police feared she would harm herself. The psychiatrist’s records showed numerous office visits and telephone calls regarding the patient’s medication.

The family also claimed that the patient was extremely frustrated by her lack of progress. The psychiatrist countered that the patient refused his recommendations for further treatment.

• The case was settled for $600,000.
  

Dr. Grant’s observations

There are obvious benefits to dealing with patients over the telephone. First, phone consultations can prevent unnecessary office visits or a trip to the emergency room,¹ especially when a patient needs reassurance rather than an assessment.

Second, telephone contact can help you cost-effectively track an acute or chronic illness.² A short telephone conversation can spare some patients the expense of an office visit.

Recent data³ suggest that care management and psychotherapy via telephone may improve clinical outcomes for patients taking antidepressants for depression. Physician-patient telephone calls average 4.3 minutes and very few are considered urgent, so most calls will not result in a legal problem.⁴

The above cases reflect what many psychiatrists do routinely: assess a patient and change medication without seeing the patient. Roughly 25% of physician-patient interactions occur over the telephone.⁴ In one-third of these interactions, however, the physician and patient disagree on the reason for the call.⁵ Given this rate of miscommunication, beware of potential legal trouble when communicating with patients by telephone.

 

Phone management pitfalls

Improper diagnosis and treatment. The American Psychiatric Association (APA) considers starting a patient relationship without a face-to-face evaluation unethical, but office evaluations are not required when changing an established treatment plan.⁶ APA’s ethics committee suggests that face-to-face evaluations of established patients are required only if “clinically necessary,” so use your knowledge of the patient and the call to determine clinical necessity.

The above cases appear to stem from the psychiatrists’ failure to detect the severity of the patients’ problems and to offer more intensive interventions. Two limitations of telephone conversation can increase the risk of missed diagnosis and delayed or inappropriate treatment:

• Telephone assessments tend to be rushed and not as systematic as an office evaluation.
  
• Making a thorough assessment is difficult without seeing the patient’s nonverbal cues.
  

For example, an otherwise well-kempt person’s disheveled appearance or a previously nonpsychotic person’s apparent responses to internal stimuli would raise a red flag during an in-person visit.⁷

Breach of confidentiality occurs when a physician provides confidential medical information to someone other than the patient without the patient’s consent.⁷ In one study assessing physician telephone calls, the physician spoke to the patient in only 79% of cases.⁸

Disclosing information without consent could violate the patient’s privacy. When a caller identifies himself as your patient, make sure you know who’s on the phone. If the caller requests confidential information (such as HIV test results) and you’re not sure that the caller is your patient, tell him you’ll call back or ask the patient to come to your office for the test results. If the caller is giving but not requesting information, you are not violating the patient’s confidentiality.

In the above cases, the psychiatrists discussed symptoms and treatment with someone other than the patient. In the first case, the psychiatrist violated the patient’s confidentiality by discussing the patient’s medication needs not with him but with his wife. In the bargain, the doctor did not get informed consent. The psychiatrist should have spoken directly to the patient or asked him for permission to discuss care with his wife. The patient might have been too confused to talk with the psychiatrist, leading the psychiatrist to offer different treatment recommendations.

Changing medication or dosages requires a thorough discussion of the drug’s side effects, benefits, and alternatives with the patient.

Telephone protocol for your practice

Talk to the patient directly. As stated, discussing the patient’s treatment with a spouse or someone else without the patient’s permission violates the patient’s privacy. Also, be cautious when interpreting information provided by someone else.

Speaking with the patient directly is crucial to accurate assessment. Without visual cues, the patient’s words become crucial.

During the phone call, have the patient repeat any instructions you give.⁹ This will minimize the risk for error.⁵

Document the call. In one study of psychiatrists receiving or making calls, only 45% documented the calls in the patient’s chart.²

Your defense against a malpractice suit could hinge on the thoroughness of documentation. Make sure you record:

• the date and time of the call
  
• the patient’s name
  
• the chief complaint and his or her disposition
  
• your assessment and any advice given
  
• necessary follow-up action
  
• requests for prescription refills
  
• and any symptoms that indicate that the patient should call back.⁷
  

For example, document that you told the patient to call back if certain serious symptoms result from a medication change, such as a rash after starting lamotrigine or signs of toxicity after increasing lithium. Otherwise, tell the patient you will call back.

How long you wait to call the patient depends on his or her condition. If he or she is fairly stable, you might call after 1 week; if the condition is more serious, you might call the next day.

Avoid managing high-risk patients over the phone. In the above cases, an urgent office visit or a recommendation to report to the nearest emergency room might have been prudent.

Discuss your phone policy during the initial visit. Ask the patient if you can leave a personal message and if his or her message service is private.

Also discuss whether you will charge for phone consultation. Insurance companies often consider telephone conversations “incidental” and usually do not reimburse them separately. From an ethical standpoint, you can charge the patient for such calls if you discuss payment during the initial treatment contact.⁶

Telephone calls to patients can be time-consuming. Although 86% of psychiatrists feel they should receive compensation for these calls, less than 1% do.²

C. Difficile Update

1. Loo VG, Poirier L, Miller MA, et al. A Predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-2449.
2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005 Dec 8;353(23):2433-2441.
3. Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North American and Europe. Lancet. 2005 Sep 24-30;366(9491):1079-1084.

In 1978, Clostridium difficile was linked to antibiotic-associated diarrhea and pseudomembranous colitis. This spore-forming gram-positive rod causes disease through two toxins—A and B—which can be detected with cytotoxin assays. It colonizes a significant proportion of hospitalized patients, but causes disease in less than 1%. The primary risk factor for developing disease is antibiotic exposure, presumably through disruption of normal gut flora. Outcomes range from mild diarrhea to life-threatening pseudomembranous colitis requiring colectomy.

Since 2000 a number of hospitals in the United States and Canada have witnessed outbreaks of C. difficile characterized by increases in both the incidence and severity of disease. Three recent publications have shed light on the changes in microbiology that have contributed to those findings. All of the studies characterized C. difficile isolates from these outbreaks, and one included information about patient outcomes.

When isolates from the outbreaks were collected, all three studies identified a predominant strain of C. difficile known as NAP1/027. It accounted for 50%-82% of isolates from the outbreaks in these studies. In contrast, NAP1/027 was present in only 14 isolates from a database of more than 6,000 strains isolated in the United States prior to 2001.

NAP1/027 has a number of concerning microbiologic characteristics. It contains a deletion in the gene tcdC, which normally suppresses the production of toxins A and B. Warny, et al. found that the NAP1/027 strain produces levels of toxins A and B that are 16 and 23 times higher, respectively, than a historically dominant strain. NAP1/027 also produces a binary toxin previously uncommon in C. difficile isolates. The role of binary toxin is not well understood, but it may mediate increased pathogenicity. Finally, the NAP1/027 strain displays high levels of fluoroquinolone resistance, which is uncommon in previous strains of C. difficile.

Loo, et al. also studied patient outcomes in 1,703 patients with C. difficile disease outbreaks in 12 Canadian hospitals. The 30-day mortality rate attributable to C. difficile infection was 6.9%, compared with 0.5-5.5% in previous studies. Patients older than 80 had a higher risk of developing C. difficile infection. For those who did, the 30-day mortality rate attributable to C. difficile was more than 10%.

The discovery of the NAP1/027 strain should strengthen our resolve to use antibiotics judiciously, to recognize and treat C. difficile infections promptly, and to implement strict isolation when cases are discovered. Special attention should be given to elderly patients, who may be at higher risk. Finally, it stresses the importance of hospital epidemiology and infection control, areas in which hospitalists can take an active role.—SM

The Controversy of Thrombolytic Therapy in Hemodynamically Stable Patients with Acute PE

Söhne M, Ten Wolde M Boomsma F, et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006 Mar;4(3):552-526.

The role of thrombolytic therapy in hemodynamically stable patients with acute pulmonary embolism is controversial. Right ventricular dysfunction can be an indication for thrombolytics in some patients, but clinical examination is limited and emergent echocardiography is unavailable in many institutions. Rapid measurement of brain natriuretic peptide (BNP) as a marker of right ventricular strain may assist with decision-making in the management of acute PE. Söhne, et al, hypothesized that BNP at presentation would predict the risk of recurrent venous thromboembolism (VTE), including fatal pulmonary embolism.

 

A nested-case control study was performed within a large, randomized-controlled study of initial treatment of pulmonary embolism. Patients with recurrent VTE within three months were each matched to three controls. BNP levels were drawn at baseline, and both hypertension and congestive heart failure were evaluated as potential confounders.

Cases had significantly higher baseline BNP values than controls (2.45 pmol/L versus 0.80 pmol/L). The odds ratio for each unit increase in the (log) BNP was 2.4 (95% CI: 1.5-3.7). Hypertension was not a confounding factor, but patients with a history of congestive heart failure had no association between elevated BNP and recurrent VTE. Using receiver-operating characteristic analysis, the optimal BNP cut-off of 1.25 pmol/L resulted in a sensitivity and specificity for recurrent VTE of 60% and 62%, respectively.

Three recent studies have suggested that BNP can be used to predict adverse outcomes in patients with pulmonary embolism, including mortality and eventual need for mechanical ventilation, cardiopulmonary resuscitation or thrombolysis. In this study, which included only hemodynamically stable patients with acute pulmonary embolism, however, BNP did not independently predict adverse outcomes. Nonetheless, BNP may be a useful adjunct to other clinical data in deciding whether or not to initiate thrombolytic therapy in pulmonary embolism patients without a history of congestive heart failure.—CR

Insulin Therapy in the ICU

Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-461.

A landmark 2001 study by Van den Berghe, et al. compared tight versus liberal control of blood sugars in surgical ICU patients. The authors found that patients randomized to intensive insulin therapy had decreased mortality during intensive care compared to those receiving conventional treatment (ARR 3.4%, NNT 29).

In this follow-up study, Van den Berghe, et al., shifted the focus toward medical ICU patients. As their previous results were most dramatic in patients who stayed in the ICU for at least five days, they recruited patients expected to require at least three ICU days.

Twelve hundred patients were randomized to receive either conventional (goal BG 180-200 mg/dl) or intensive (goal BG 80-110 mg/dl) insulin treatment. The primary end point was all-cause mortality in the hospital. Secondary outcomes were also defined, including ICU mortality, 90-day mortality, days to weaning from mechanical ventilation, days in the ICU and in the hospital, renal failure, and incidence of bacteremia.

In the intention-to-treat analysis, there was no statistically significant difference in the primary end point of in-hospital mortality. Predefined subgroup analysis of patients who stayed in the ICU longer than three days showed a significant mortality benefit for the intensive insulin regimen (ARR 6.8%, NNT 15). However, in the subgroup of patients staying less than three days in the ICU, there was increased risk of death from all causes (ARI 8.2%, NNH 12). This finding did or did not meet statistical significance depending on the statistical method employed. Some secondary outcome measures assessing morbidity suggested a benefit of intensive insulin therapy. These included a reduction in kidney failure (ARR 3%, NNT 33), earlier weaning from mechanical ventilation, and earlier discharge from the ICU and from the hospital.

The results of this important study are sure to fuel more debate on ideal goals for blood sugar control in the critically ill. The study confirms previous findings that intensive insulin management improves mortality in patients with longer stays in the ICU. As length of stay in the ICU is difficult to predict in advance, the possibility of tight glycemic control increasing mortality in patients with short ICU stays complicates the decision to implement intensive insulin therapy. These results should especially give us pause in extrapolating the original study results to our sick floor patients.—RH

 

LMWH or UFH for High-Risk Patients with ACS

Mahaffey KW, Cohen M, Garg J, et al. High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial. JAMA. 2005 Nov 23;294(20):2594-2600.

In July 2004 the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) trial reported 30-day post hospitalization data. This study compared low molecular weight heparin (LMWH) to unfractionated heparin (UFH) during acute coronary syndrome (ACS) and found it “at least as effective” as UFH. Further data extending to six months and 12 months was reported in November.

This prospective, randomized, open-labeled multicentered trial enrolled 9,978 patients and compared LMWH versus UFH in ACS. Enrolled patients had had active ischemic symptoms within 24 hours of enrollment, and met two of the following three criteria:

1. Age 60 or older;
2. Elevated cardiac enzymes; and
3. Ischemic ECG changes other than ST elevations.

All patients were treated with standard medical therapy with 50% in both groups receiving GIIb/IIIa inhibitors. Interventions were pursued equally in both groups of patients; 92% had angiograms within 24 hours, 47% had percutaneous interventions, and 19% underwent coronary artery bypass grafting during the index hospitalization.

Six-month and 12-month data confirmed that LMWH use was noninferior to UFH. At six months there was no significant difference between the groups in frequency of nonfatal MI, further revascularization, CVA, or hospitalization. At 12 months, all cause mortality was found to be equivalent between the two groups. Interestingly, nearly 18% died or experienced nonfatal MI through six months of follow-up and 7.4% died by one-year follow-up, despite aggressive coronary revascularization and high use of evidence-based therapies at the time of hospital discharge.

When compared with other trials, these higher than “normal” rates of death and MI were believed related to the high-risk patient population and a lower threshold of cardiac enzyme abnormality. In this high-risk group of patients, LMWH and UFH appear to be equally safe and efficacious for the treatment of ACS, with equivalent long-term outcomes.—RM TH

C. Difficile Update

1. Loo VG, Poirier L, Miller MA, et al. A Predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-2449.
2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005 Dec 8;353(23):2433-2441.
3. Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North American and Europe. Lancet. 2005 Sep 24-30;366(9491):1079-1084.

In 1978, Clostridium difficile was linked to antibiotic-associated diarrhea and pseudomembranous colitis. This spore-forming gram-positive rod causes disease through two toxins—A and B—which can be detected with cytotoxin assays. It colonizes a significant proportion of hospitalized patients, but causes disease in less than 1%. The primary risk factor for developing disease is antibiotic exposure, presumably through disruption of normal gut flora. Outcomes range from mild diarrhea to life-threatening pseudomembranous colitis requiring colectomy.

Since 2000 a number of hospitals in the United States and Canada have witnessed outbreaks of C. difficile characterized by increases in both the incidence and severity of disease. Three recent publications have shed light on the changes in microbiology that have contributed to those findings. All of the studies characterized C. difficile isolates from these outbreaks, and one included information about patient outcomes.

When isolates from the outbreaks were collected, all three studies identified a predominant strain of C. difficile known as NAP1/027. It accounted for 50%-82% of isolates from the outbreaks in these studies. In contrast, NAP1/027 was present in only 14 isolates from a database of more than 6,000 strains isolated in the United States prior to 2001.

NAP1/027 has a number of concerning microbiologic characteristics. It contains a deletion in the gene tcdC, which normally suppresses the production of toxins A and B. Warny, et al. found that the NAP1/027 strain produces levels of toxins A and B that are 16 and 23 times higher, respectively, than a historically dominant strain. NAP1/027 also produces a binary toxin previously uncommon in C. difficile isolates. The role of binary toxin is not well understood, but it may mediate increased pathogenicity. Finally, the NAP1/027 strain displays high levels of fluoroquinolone resistance, which is uncommon in previous strains of C. difficile.

Loo, et al. also studied patient outcomes in 1,703 patients with C. difficile disease outbreaks in 12 Canadian hospitals. The 30-day mortality rate attributable to C. difficile infection was 6.9%, compared with 0.5-5.5% in previous studies. Patients older than 80 had a higher risk of developing C. difficile infection. For those who did, the 30-day mortality rate attributable to C. difficile was more than 10%.

The discovery of the NAP1/027 strain should strengthen our resolve to use antibiotics judiciously, to recognize and treat C. difficile infections promptly, and to implement strict isolation when cases are discovered. Special attention should be given to elderly patients, who may be at higher risk. Finally, it stresses the importance of hospital epidemiology and infection control, areas in which hospitalists can take an active role.—SM

The Controversy of Thrombolytic Therapy in Hemodynamically Stable Patients with Acute PE

Söhne M, Ten Wolde M Boomsma F, et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006 Mar;4(3):552-526.

The role of thrombolytic therapy in hemodynamically stable patients with acute pulmonary embolism is controversial. Right ventricular dysfunction can be an indication for thrombolytics in some patients, but clinical examination is limited and emergent echocardiography is unavailable in many institutions. Rapid measurement of brain natriuretic peptide (BNP) as a marker of right ventricular strain may assist with decision-making in the management of acute PE. Söhne, et al, hypothesized that BNP at presentation would predict the risk of recurrent venous thromboembolism (VTE), including fatal pulmonary embolism.

 

A nested-case control study was performed within a large, randomized-controlled study of initial treatment of pulmonary embolism. Patients with recurrent VTE within three months were each matched to three controls. BNP levels were drawn at baseline, and both hypertension and congestive heart failure were evaluated as potential confounders.

Cases had significantly higher baseline BNP values than controls (2.45 pmol/L versus 0.80 pmol/L). The odds ratio for each unit increase in the (log) BNP was 2.4 (95% CI: 1.5-3.7). Hypertension was not a confounding factor, but patients with a history of congestive heart failure had no association between elevated BNP and recurrent VTE. Using receiver-operating characteristic analysis, the optimal BNP cut-off of 1.25 pmol/L resulted in a sensitivity and specificity for recurrent VTE of 60% and 62%, respectively.

Three recent studies have suggested that BNP can be used to predict adverse outcomes in patients with pulmonary embolism, including mortality and eventual need for mechanical ventilation, cardiopulmonary resuscitation or thrombolysis. In this study, which included only hemodynamically stable patients with acute pulmonary embolism, however, BNP did not independently predict adverse outcomes. Nonetheless, BNP may be a useful adjunct to other clinical data in deciding whether or not to initiate thrombolytic therapy in pulmonary embolism patients without a history of congestive heart failure.—CR

Insulin Therapy in the ICU

Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-461.

A landmark 2001 study by Van den Berghe, et al. compared tight versus liberal control of blood sugars in surgical ICU patients. The authors found that patients randomized to intensive insulin therapy had decreased mortality during intensive care compared to those receiving conventional treatment (ARR 3.4%, NNT 29).

In this follow-up study, Van den Berghe, et al., shifted the focus toward medical ICU patients. As their previous results were most dramatic in patients who stayed in the ICU for at least five days, they recruited patients expected to require at least three ICU days.

Twelve hundred patients were randomized to receive either conventional (goal BG 180-200 mg/dl) or intensive (goal BG 80-110 mg/dl) insulin treatment. The primary end point was all-cause mortality in the hospital. Secondary outcomes were also defined, including ICU mortality, 90-day mortality, days to weaning from mechanical ventilation, days in the ICU and in the hospital, renal failure, and incidence of bacteremia.

In the intention-to-treat analysis, there was no statistically significant difference in the primary end point of in-hospital mortality. Predefined subgroup analysis of patients who stayed in the ICU longer than three days showed a significant mortality benefit for the intensive insulin regimen (ARR 6.8%, NNT 15). However, in the subgroup of patients staying less than three days in the ICU, there was increased risk of death from all causes (ARI 8.2%, NNH 12). This finding did or did not meet statistical significance depending on the statistical method employed. Some secondary outcome measures assessing morbidity suggested a benefit of intensive insulin therapy. These included a reduction in kidney failure (ARR 3%, NNT 33), earlier weaning from mechanical ventilation, and earlier discharge from the ICU and from the hospital.

The results of this important study are sure to fuel more debate on ideal goals for blood sugar control in the critically ill. The study confirms previous findings that intensive insulin management improves mortality in patients with longer stays in the ICU. As length of stay in the ICU is difficult to predict in advance, the possibility of tight glycemic control increasing mortality in patients with short ICU stays complicates the decision to implement intensive insulin therapy. These results should especially give us pause in extrapolating the original study results to our sick floor patients.—RH

 

LMWH or UFH for High-Risk Patients with ACS

Mahaffey KW, Cohen M, Garg J, et al. High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial. JAMA. 2005 Nov 23;294(20):2594-2600.

In July 2004 the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) trial reported 30-day post hospitalization data. This study compared low molecular weight heparin (LMWH) to unfractionated heparin (UFH) during acute coronary syndrome (ACS) and found it “at least as effective” as UFH. Further data extending to six months and 12 months was reported in November.

This prospective, randomized, open-labeled multicentered trial enrolled 9,978 patients and compared LMWH versus UFH in ACS. Enrolled patients had had active ischemic symptoms within 24 hours of enrollment, and met two of the following three criteria:

1. Age 60 or older;
2. Elevated cardiac enzymes; and
3. Ischemic ECG changes other than ST elevations.

All patients were treated with standard medical therapy with 50% in both groups receiving GIIb/IIIa inhibitors. Interventions were pursued equally in both groups of patients; 92% had angiograms within 24 hours, 47% had percutaneous interventions, and 19% underwent coronary artery bypass grafting during the index hospitalization.

Six-month and 12-month data confirmed that LMWH use was noninferior to UFH. At six months there was no significant difference between the groups in frequency of nonfatal MI, further revascularization, CVA, or hospitalization. At 12 months, all cause mortality was found to be equivalent between the two groups. Interestingly, nearly 18% died or experienced nonfatal MI through six months of follow-up and 7.4% died by one-year follow-up, despite aggressive coronary revascularization and high use of evidence-based therapies at the time of hospital discharge.

When compared with other trials, these higher than “normal” rates of death and MI were believed related to the high-risk patient population and a lower threshold of cardiac enzyme abnormality. In this high-risk group of patients, LMWH and UFH appear to be equally safe and efficacious for the treatment of ACS, with equivalent long-term outcomes.—RM TH

C. Difficile Update

1. Loo VG, Poirier L, Miller MA, et al. A Predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-2449.
2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005 Dec 8;353(23):2433-2441.
3. Warny M, Pepin J, Fang A, et al. Toxin production by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North American and Europe. Lancet. 2005 Sep 24-30;366(9491):1079-1084.

In 1978, Clostridium difficile was linked to antibiotic-associated diarrhea and pseudomembranous colitis. This spore-forming gram-positive rod causes disease through two toxins—A and B—which can be detected with cytotoxin assays. It colonizes a significant proportion of hospitalized patients, but causes disease in less than 1%. The primary risk factor for developing disease is antibiotic exposure, presumably through disruption of normal gut flora. Outcomes range from mild diarrhea to life-threatening pseudomembranous colitis requiring colectomy.

Since 2000 a number of hospitals in the United States and Canada have witnessed outbreaks of C. difficile characterized by increases in both the incidence and severity of disease. Three recent publications have shed light on the changes in microbiology that have contributed to those findings. All of the studies characterized C. difficile isolates from these outbreaks, and one included information about patient outcomes.

When isolates from the outbreaks were collected, all three studies identified a predominant strain of C. difficile known as NAP1/027. It accounted for 50%-82% of isolates from the outbreaks in these studies. In contrast, NAP1/027 was present in only 14 isolates from a database of more than 6,000 strains isolated in the United States prior to 2001.

NAP1/027 has a number of concerning microbiologic characteristics. It contains a deletion in the gene tcdC, which normally suppresses the production of toxins A and B. Warny, et al. found that the NAP1/027 strain produces levels of toxins A and B that are 16 and 23 times higher, respectively, than a historically dominant strain. NAP1/027 also produces a binary toxin previously uncommon in C. difficile isolates. The role of binary toxin is not well understood, but it may mediate increased pathogenicity. Finally, the NAP1/027 strain displays high levels of fluoroquinolone resistance, which is uncommon in previous strains of C. difficile.

Loo, et al. also studied patient outcomes in 1,703 patients with C. difficile disease outbreaks in 12 Canadian hospitals. The 30-day mortality rate attributable to C. difficile infection was 6.9%, compared with 0.5-5.5% in previous studies. Patients older than 80 had a higher risk of developing C. difficile infection. For those who did, the 30-day mortality rate attributable to C. difficile was more than 10%.

The discovery of the NAP1/027 strain should strengthen our resolve to use antibiotics judiciously, to recognize and treat C. difficile infections promptly, and to implement strict isolation when cases are discovered. Special attention should be given to elderly patients, who may be at higher risk. Finally, it stresses the importance of hospital epidemiology and infection control, areas in which hospitalists can take an active role.—SM

The Controversy of Thrombolytic Therapy in Hemodynamically Stable Patients with Acute PE

Söhne M, Ten Wolde M Boomsma F, et al. Brain natriuretic peptide in hemodynamically stable acute pulmonary embolism. J Thromb Haemost. 2006 Mar;4(3):552-526.

The role of thrombolytic therapy in hemodynamically stable patients with acute pulmonary embolism is controversial. Right ventricular dysfunction can be an indication for thrombolytics in some patients, but clinical examination is limited and emergent echocardiography is unavailable in many institutions. Rapid measurement of brain natriuretic peptide (BNP) as a marker of right ventricular strain may assist with decision-making in the management of acute PE. Söhne, et al, hypothesized that BNP at presentation would predict the risk of recurrent venous thromboembolism (VTE), including fatal pulmonary embolism.

 

A nested-case control study was performed within a large, randomized-controlled study of initial treatment of pulmonary embolism. Patients with recurrent VTE within three months were each matched to three controls. BNP levels were drawn at baseline, and both hypertension and congestive heart failure were evaluated as potential confounders.

Cases had significantly higher baseline BNP values than controls (2.45 pmol/L versus 0.80 pmol/L). The odds ratio for each unit increase in the (log) BNP was 2.4 (95% CI: 1.5-3.7). Hypertension was not a confounding factor, but patients with a history of congestive heart failure had no association between elevated BNP and recurrent VTE. Using receiver-operating characteristic analysis, the optimal BNP cut-off of 1.25 pmol/L resulted in a sensitivity and specificity for recurrent VTE of 60% and 62%, respectively.

Three recent studies have suggested that BNP can be used to predict adverse outcomes in patients with pulmonary embolism, including mortality and eventual need for mechanical ventilation, cardiopulmonary resuscitation or thrombolysis. In this study, which included only hemodynamically stable patients with acute pulmonary embolism, however, BNP did not independently predict adverse outcomes. Nonetheless, BNP may be a useful adjunct to other clinical data in deciding whether or not to initiate thrombolytic therapy in pulmonary embolism patients without a history of congestive heart failure.—CR

Insulin Therapy in the ICU

Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-461.

A landmark 2001 study by Van den Berghe, et al. compared tight versus liberal control of blood sugars in surgical ICU patients. The authors found that patients randomized to intensive insulin therapy had decreased mortality during intensive care compared to those receiving conventional treatment (ARR 3.4%, NNT 29).

In this follow-up study, Van den Berghe, et al., shifted the focus toward medical ICU patients. As their previous results were most dramatic in patients who stayed in the ICU for at least five days, they recruited patients expected to require at least three ICU days.

Twelve hundred patients were randomized to receive either conventional (goal BG 180-200 mg/dl) or intensive (goal BG 80-110 mg/dl) insulin treatment. The primary end point was all-cause mortality in the hospital. Secondary outcomes were also defined, including ICU mortality, 90-day mortality, days to weaning from mechanical ventilation, days in the ICU and in the hospital, renal failure, and incidence of bacteremia.

In the intention-to-treat analysis, there was no statistically significant difference in the primary end point of in-hospital mortality. Predefined subgroup analysis of patients who stayed in the ICU longer than three days showed a significant mortality benefit for the intensive insulin regimen (ARR 6.8%, NNT 15). However, in the subgroup of patients staying less than three days in the ICU, there was increased risk of death from all causes (ARI 8.2%, NNH 12). This finding did or did not meet statistical significance depending on the statistical method employed. Some secondary outcome measures assessing morbidity suggested a benefit of intensive insulin therapy. These included a reduction in kidney failure (ARR 3%, NNT 33), earlier weaning from mechanical ventilation, and earlier discharge from the ICU and from the hospital.

The results of this important study are sure to fuel more debate on ideal goals for blood sugar control in the critically ill. The study confirms previous findings that intensive insulin management improves mortality in patients with longer stays in the ICU. As length of stay in the ICU is difficult to predict in advance, the possibility of tight glycemic control increasing mortality in patients with short ICU stays complicates the decision to implement intensive insulin therapy. These results should especially give us pause in extrapolating the original study results to our sick floor patients.—RH

 

LMWH or UFH for High-Risk Patients with ACS

Mahaffey KW, Cohen M, Garg J, et al. High-risk patients with acute coronary syndromes treated with low-molecular-weight or unfractionated heparin: outcomes at 6 months and 1 year in the SYNERGY trial. JAMA. 2005 Nov 23;294(20):2594-2600.

In July 2004 the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) trial reported 30-day post hospitalization data. This study compared low molecular weight heparin (LMWH) to unfractionated heparin (UFH) during acute coronary syndrome (ACS) and found it “at least as effective” as UFH. Further data extending to six months and 12 months was reported in November.

This prospective, randomized, open-labeled multicentered trial enrolled 9,978 patients and compared LMWH versus UFH in ACS. Enrolled patients had had active ischemic symptoms within 24 hours of enrollment, and met two of the following three criteria:

1. Age 60 or older;
2. Elevated cardiac enzymes; and
3. Ischemic ECG changes other than ST elevations.

All patients were treated with standard medical therapy with 50% in both groups receiving GIIb/IIIa inhibitors. Interventions were pursued equally in both groups of patients; 92% had angiograms within 24 hours, 47% had percutaneous interventions, and 19% underwent coronary artery bypass grafting during the index hospitalization.

Six-month and 12-month data confirmed that LMWH use was noninferior to UFH. At six months there was no significant difference between the groups in frequency of nonfatal MI, further revascularization, CVA, or hospitalization. At 12 months, all cause mortality was found to be equivalent between the two groups. Interestingly, nearly 18% died or experienced nonfatal MI through six months of follow-up and 7.4% died by one-year follow-up, despite aggressive coronary revascularization and high use of evidence-based therapies at the time of hospital discharge.

When compared with other trials, these higher than “normal” rates of death and MI were believed related to the high-risk patient population and a lower threshold of cardiac enzyme abnormality. In this high-risk group of patients, LMWH and UFH appear to be equally safe and efficacious for the treatment of ACS, with equivalent long-term outcomes.—RM TH

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. Mar;2003:25(2);177-181.

Many hospitalists are involved in processes to reduce errors in the hospital. Given the dozens of clinical decisions hospitalists make each day, errors in clinical reasoning are worth exploring. However, few physicians are familiar with the terminology and classes of clinical reasoning errors as described in the literature.

This article outlines two models of clinical reasoning and explains common biases that distort clinical reasoning. Although the examples used to illustrate these errors draw from primary care internal medicine, they are easily recognizable.

Biases are defined as inaccurate beliefs that affect decision-making.

When generating a differential diagnosis, the bias of availability (aka recall bias) involves a clinician being influenced by what is easily recalled, creating a false sense of prevalence. This is especially common with less experienced clinicians, residents, and medical students.

The bias of representativeness (aka judging by similarity) involves the physician choosing a diagnosis based solely on signs and symptoms, while neglecting the prevalence of competing diagnoses.

The bias of confirmation involves the clinician using additional testing to confirm a suspected diagnosis, but failing to test competing hypotheses.

The bias of anchoring and adjustment involves the clinician inadequately adjusting the differential in light of new data.

The bias of bounded rationality (aka search satisfying) involves the clinician stopping the search for additional diagnoses after the anticipated diagnosis has been made.

Outcome bias involves judging a clinical decision retrospectively based on the outcome, rather than on logic and evidence supporting the original decision.

Omission bias involves placing undue emphasis on avoiding the adverse effect of a therapy, leading to under-utilization of a beneficial treatment.

Most of the work in clinical reasoning errors is published in the cognitive psychology and education literature, which most hospitalists do not regularly read. By becoming familiar with the concepts and terminology, hospitalists can more readily engage in discussions of clinical reasoning errors and how to avoid them. TH

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team—from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Several months ago, a patient with decompensated end-stage liver disease was admitted to the Internal Medicine Hospitalist Service at the University of Texas Medical Branch in Galveston and required a paracentesis. One of the new hospitalist faculty members was taken aback when the physician assistant (PA) on the service volunteered to do the procedure. “He was surprised,” says Karen Kislingbury, PA-C, a member of SHM’s Non-Physician Provider Task Force and a PA with the Internal Medicine Hospitalist Service, “that the scope of practice for the physician assistant included [performing] procedures.”

PAs are not new to the hospital setting, and their inclusion as physician extenders to increase patient access to care will likely increase in the current regulatory environment—especially state-mandated staff/patient ratios and resident work hour limitations. The efficacy of utilizing physician extenders to improve patient care and outcomes has been validated in studies over the past two decades. A recent Journal of Trauma study found statistically significant reductions in floor, ICU, and overall hospital lengths of stay after incorporating physician extenders into their trauma service.1

However, hospitalists unfamiliar with PAs may not understand their colleagues’ roles and scope of practice. As her anecdote illustrated, Kislingbury notes that “although PAs aren’t new to the healthcare delivery system, and physicians have been utilizing us for a long time, our partnership in the unique setting of hospital medicine is kind of new.”

Kislingbury’s colleague Ryan Genzink, PA-C, who works with Hospitalists of West Michigan, a private hospitalists-only group that subcontracts hospitalist services to Spectrum Health of Grand Rapids, Mich., agrees with her assessment.

“There are more and more PAs and [nurse practitioners] working in hospital medicine, and I think there is a lot of curiosity and some apprehension on the part of people who have not worked with these non-physician providers,” says Genzink.

Genzink, also a member of SHM’s Non-Physician Provider Task Force, speculates that the apprehension of physicians who have not worked with PAs may be due to a misunderstanding of the PA’s role. “They’re either underestimating or overestimating exactly what a PA can do or what they are getting when they hire a PA,” he says.

A Short History of the Profession

PA programs officially began in the mid-1960s at Duke University Medical School (Durham, N.C.). Eugene Stead, MD, is credited with developing the concept of the physician assistant as a health professional who would work with physician supervision to extend patient access to care, according to the American Academy of Physician Assistants.

For the first class of PAs in 1965, Dr. Stead selected Navy corpsmen who had received medical training and experience during their service in Vietnam. The curriculum was based on Dr. Stead’s knowledge of fast-track training of physicians during World War II. From this early program, the profession has evolved to more than 130 programs that now adhere to rigorous national accreditation standards set forth by the independent Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA is sponsored by the American Medical Association and the American College of Surgeons, among many other professional medical organizations (www.aapa.org/geninfo1.html).

 

Scope of Practice

Prerequisites to PA programs include two years of college courses in basic and behavioral science, as well as prior experience in healthcare. According to a report generated by the Association of Physician Assistant Programs, most PA students have earned a bachelor’s degree and have an average of 38 months of healthcare experience before being admitted to a PA program.2

The first year of PA education comprises a didactic curriculum with coursework in anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of rotations—typically in family and internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. By the time they graduate (typical PA programs last an average of 26 months), PAs will have completed more than 2,000 hours of supervised clinical practice.

PAs work in all areas of medicine. Although hospital bylaws and state regulations often stipulate the PA’s scope of practice, the major determinant of duties is the supervising physician. The relationship between supervising physician and PA, says Kislingbury, is a collaborative one. Duties are “defined on an individual basis, and they are determined based on our [PAs’] experience, the physicians’ experience with us, and then the nuances of the system and the hospital itself.

“The PA who is hired should know what his or her scope of practice is,” she continues. “By the time they have graduated and obtained their license, they should know what their state allows them to do.”

For instance, according to the American Academy of Physician Assistants, 48 of the 50 states, plus the District of Columbia and [the U.S. Territory of] Guam, authorize PAs to prescribe medications. In California, PA prescriptions are referred to as “written prescription transmittal orders.”

“For the most part,” says Genzink, “the supervising physician determines what the PA is capable of doing, within the guidelines of state law.”

Within Genzink’s hospital medicine group (with which he has been affiliated for five years) the physician and PA roles are very similar.

“We see the same type of patients in a team approach. For instance, it’s not uncommon for one of us to order a test early in the day, and then, when results come back, the other person may be discharging that patient or prescribing other treatments, if necessary,” he explains. “In general, the physicians take care of the more complicated patients, while PAs take care of more routine patients.”

Genzink’s group experience aligns with findings of a 1998 University of Pittsburgh School of Nursing Study, which evaluated provider roles and patient outcomes in an acute care setting.3 Compared with acute care nurse practitioners and PAs, residents in that study tended to care for patients who were older and sicker.

Genzink reports that in his group initial histories and physicals, as well as the consultations, are performed exclusively by the PAs and then the physician takes over for treatment. “Based on the acuity of the patient,” says Genzink, “the physician may be right down there to see the patient immediately.”

Areas for Improvement?

Although the two PAs interviewed for this article report positive experiences working with hospitalists, they admit that some physicians continue to hold misperceptions about the PA’s role in caring for patients.

Kislingbury says that hospitalists could improve their delegation of duties to the PAs and recognize their scope of practice. She admits that delegation duties can be improved through gaining experience. “Although the PA profession has been around for a while, there are a surprising number of institutions that do not utilize physician assistants on the wards in routine rounds and bedside-type care,” says Kislingbury.

 

“I think some of the problems develop when they [physicians] hire a PA and expect to get a physician—and they [don’t],” says Genzink. “The easiest way for me to explain the role is to compare it to a teaching model. All physicians have been through residency programs. They understand the hierarchy that involves training and teaching residents. PAs come out of school ‘green,’ with the assumption that training will go on at the workplace. So, if a physician takes the same stance toward a new PA as they would toward an intern, that is a pretty close comparison.

“You begin by letting PAs or interns do a few simple things, and as they master those, you teach them more,” he continues. “And then, hopefully, over time they’ve been able to master everything that the physician is able to master. [Employing a PA] is a significant investment. And, it takes time. Sometimes, that process can be very easy, depending on the person. Sometimes it can be very slow, and I think that’s sometimes where some of the frustration may come in.”

Genzink adds that in his hospital medicine group, the physicians are familiar with the idea that part of their job as supervising physicians is to train new PAs.

Kislingbury points that out that PAs can also play a role in informing the physician team members about the range of cases they are allowed to treat, thus furthering the collaboration between PAs and hospitalists: “It is merely a matter of educating the team members about what we can and cannot do.”

Accordingly, the SHM Non-Physician Provider Task Force was formed to provide a resource to hospitalists who work with PAs and have questions about scope of practice, reimbursement, and other issues as they pertain to PAs and nurse practitioners. (Visit www.hospitalmedicine.org for more information.) The Task Force is a resource for non-physicians providers, too, offering educational opportunities at SHM meetings, more visibility with the specialty, and a voice for advocacy.

The Positives of the Collaboration

While the PAs report that hospitalists could improve in communicating about their practice roles with PAs, “There are so many things that hospitalists do right!” says Kislingbury. Calling the experience of working with hospitalists a privilege, she says that “where it is a true partnership, we are treated as equals, we are given the responsibility that our experience will allow, and we are truly team members.

“Hospitalists are geared into the efficiencies of the system and the nuances of the hospital. These are subtleties that come with practicing in an area for a long period of time, not just coming in for a month and then leaving and returning,” she says. “Hospitalists know the daily ins and outs, and it is really a pleasure to learn from them.”

Prior to his affiliation with Hospitalists of West Michigan, Genzink was employed directly by a hospital in Grand Rapids. The physicians with whom he now works have been hospitalists almost exclusively throughout their medical careers. “One of the main benefits they offer is availability, simply because we [the group’s practice members] are in the hospital 24/7,” he says. “They also have more experience in dealing with more complex issues, just as do the PAs that are working in our system.”

What about the notion that PAs and nurse practitioners are more skilled or practiced with patient and family communications? One study by Rudy, et al. found that nurse practitioners and PAs were more likely than residents to discuss patients with bedside nurses and to interact with patients’ families.3 Genzink does not find this to be the case in his group’s practice.

 

“That presumption [that PAs are more communicative with families and patients] may have come about simply because as the demands on hospitalists continue to grow and the workload increases, adding the PA to the team means there are more people to do things like that [handle family communications],” he says. “Certainly, in our group, the PAs do lots of patient education, and we talk to patients about end-of-life issues and other difficult matters as well. But that is not delegated to them; in our group, both the PAs and the physicians participate equally in patient and family communication.”

Daily Learning

Hospitalists and PAs also complement each other in the interdisciplinary care team because, “as a general rule, hospitalists love to teach,” says Kislingbury. “They don’t forget that just because you have your PA degree your learning does not stop there. The PA profession is almost like on-the-job training. You are allowed to choose the specialty that you want, and you gain your experience when you enter that [arena], as opposed to an internship or residency, where you first gain experience and then enter the specialty. We so appreciate the ability of the hospitalist to teach because we are learning while doing, on a day-to-day basis. It’s invaluable to have their teaching.” TH

Gretchen Henkel also writes about dealing with difficult families in this issue.

Resources

1. Christmas AB, Reynolds J, Hodges S, et al. Physician extenders impact trauma systems. J Trauma. 2005 May;58(5):917-920.
2. Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2203. Alexandria, Va. Association of Physician Assistant Programs.
3. Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care. 1998 Jul;7(4):267-281.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team—from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Several months ago, a patient with decompensated end-stage liver disease was admitted to the Internal Medicine Hospitalist Service at the University of Texas Medical Branch in Galveston and required a paracentesis. One of the new hospitalist faculty members was taken aback when the physician assistant (PA) on the service volunteered to do the procedure. “He was surprised,” says Karen Kislingbury, PA-C, a member of SHM’s Non-Physician Provider Task Force and a PA with the Internal Medicine Hospitalist Service, “that the scope of practice for the physician assistant included [performing] procedures.”

PAs are not new to the hospital setting, and their inclusion as physician extenders to increase patient access to care will likely increase in the current regulatory environment—especially state-mandated staff/patient ratios and resident work hour limitations. The efficacy of utilizing physician extenders to improve patient care and outcomes has been validated in studies over the past two decades. A recent Journal of Trauma study found statistically significant reductions in floor, ICU, and overall hospital lengths of stay after incorporating physician extenders into their trauma service.1

However, hospitalists unfamiliar with PAs may not understand their colleagues’ roles and scope of practice. As her anecdote illustrated, Kislingbury notes that “although PAs aren’t new to the healthcare delivery system, and physicians have been utilizing us for a long time, our partnership in the unique setting of hospital medicine is kind of new.”

Kislingbury’s colleague Ryan Genzink, PA-C, who works with Hospitalists of West Michigan, a private hospitalists-only group that subcontracts hospitalist services to Spectrum Health of Grand Rapids, Mich., agrees with her assessment.

“There are more and more PAs and [nurse practitioners] working in hospital medicine, and I think there is a lot of curiosity and some apprehension on the part of people who have not worked with these non-physician providers,” says Genzink.

Genzink, also a member of SHM’s Non-Physician Provider Task Force, speculates that the apprehension of physicians who have not worked with PAs may be due to a misunderstanding of the PA’s role. “They’re either underestimating or overestimating exactly what a PA can do or what they are getting when they hire a PA,” he says.

A Short History of the Profession

PA programs officially began in the mid-1960s at Duke University Medical School (Durham, N.C.). Eugene Stead, MD, is credited with developing the concept of the physician assistant as a health professional who would work with physician supervision to extend patient access to care, according to the American Academy of Physician Assistants.

For the first class of PAs in 1965, Dr. Stead selected Navy corpsmen who had received medical training and experience during their service in Vietnam. The curriculum was based on Dr. Stead’s knowledge of fast-track training of physicians during World War II. From this early program, the profession has evolved to more than 130 programs that now adhere to rigorous national accreditation standards set forth by the independent Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA is sponsored by the American Medical Association and the American College of Surgeons, among many other professional medical organizations (www.aapa.org/geninfo1.html).

 

Scope of Practice

Prerequisites to PA programs include two years of college courses in basic and behavioral science, as well as prior experience in healthcare. According to a report generated by the Association of Physician Assistant Programs, most PA students have earned a bachelor’s degree and have an average of 38 months of healthcare experience before being admitted to a PA program.2

The first year of PA education comprises a didactic curriculum with coursework in anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of rotations—typically in family and internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. By the time they graduate (typical PA programs last an average of 26 months), PAs will have completed more than 2,000 hours of supervised clinical practice.

PAs work in all areas of medicine. Although hospital bylaws and state regulations often stipulate the PA’s scope of practice, the major determinant of duties is the supervising physician. The relationship between supervising physician and PA, says Kislingbury, is a collaborative one. Duties are “defined on an individual basis, and they are determined based on our [PAs’] experience, the physicians’ experience with us, and then the nuances of the system and the hospital itself.

“The PA who is hired should know what his or her scope of practice is,” she continues. “By the time they have graduated and obtained their license, they should know what their state allows them to do.”

For instance, according to the American Academy of Physician Assistants, 48 of the 50 states, plus the District of Columbia and [the U.S. Territory of] Guam, authorize PAs to prescribe medications. In California, PA prescriptions are referred to as “written prescription transmittal orders.”

“For the most part,” says Genzink, “the supervising physician determines what the PA is capable of doing, within the guidelines of state law.”

Within Genzink’s hospital medicine group (with which he has been affiliated for five years) the physician and PA roles are very similar.

“We see the same type of patients in a team approach. For instance, it’s not uncommon for one of us to order a test early in the day, and then, when results come back, the other person may be discharging that patient or prescribing other treatments, if necessary,” he explains. “In general, the physicians take care of the more complicated patients, while PAs take care of more routine patients.”

Genzink’s group experience aligns with findings of a 1998 University of Pittsburgh School of Nursing Study, which evaluated provider roles and patient outcomes in an acute care setting.3 Compared with acute care nurse practitioners and PAs, residents in that study tended to care for patients who were older and sicker.

Genzink reports that in his group initial histories and physicals, as well as the consultations, are performed exclusively by the PAs and then the physician takes over for treatment. “Based on the acuity of the patient,” says Genzink, “the physician may be right down there to see the patient immediately.”

Areas for Improvement?

Although the two PAs interviewed for this article report positive experiences working with hospitalists, they admit that some physicians continue to hold misperceptions about the PA’s role in caring for patients.

Kislingbury says that hospitalists could improve their delegation of duties to the PAs and recognize their scope of practice. She admits that delegation duties can be improved through gaining experience. “Although the PA profession has been around for a while, there are a surprising number of institutions that do not utilize physician assistants on the wards in routine rounds and bedside-type care,” says Kislingbury.

 

“I think some of the problems develop when they [physicians] hire a PA and expect to get a physician—and they [don’t],” says Genzink. “The easiest way for me to explain the role is to compare it to a teaching model. All physicians have been through residency programs. They understand the hierarchy that involves training and teaching residents. PAs come out of school ‘green,’ with the assumption that training will go on at the workplace. So, if a physician takes the same stance toward a new PA as they would toward an intern, that is a pretty close comparison.

“You begin by letting PAs or interns do a few simple things, and as they master those, you teach them more,” he continues. “And then, hopefully, over time they’ve been able to master everything that the physician is able to master. [Employing a PA] is a significant investment. And, it takes time. Sometimes, that process can be very easy, depending on the person. Sometimes it can be very slow, and I think that’s sometimes where some of the frustration may come in.”

Genzink adds that in his hospital medicine group, the physicians are familiar with the idea that part of their job as supervising physicians is to train new PAs.

Kislingbury points that out that PAs can also play a role in informing the physician team members about the range of cases they are allowed to treat, thus furthering the collaboration between PAs and hospitalists: “It is merely a matter of educating the team members about what we can and cannot do.”

Accordingly, the SHM Non-Physician Provider Task Force was formed to provide a resource to hospitalists who work with PAs and have questions about scope of practice, reimbursement, and other issues as they pertain to PAs and nurse practitioners. (Visit www.hospitalmedicine.org for more information.) The Task Force is a resource for non-physicians providers, too, offering educational opportunities at SHM meetings, more visibility with the specialty, and a voice for advocacy.

The Positives of the Collaboration

While the PAs report that hospitalists could improve in communicating about their practice roles with PAs, “There are so many things that hospitalists do right!” says Kislingbury. Calling the experience of working with hospitalists a privilege, she says that “where it is a true partnership, we are treated as equals, we are given the responsibility that our experience will allow, and we are truly team members.

“Hospitalists are geared into the efficiencies of the system and the nuances of the hospital. These are subtleties that come with practicing in an area for a long period of time, not just coming in for a month and then leaving and returning,” she says. “Hospitalists know the daily ins and outs, and it is really a pleasure to learn from them.”

Prior to his affiliation with Hospitalists of West Michigan, Genzink was employed directly by a hospital in Grand Rapids. The physicians with whom he now works have been hospitalists almost exclusively throughout their medical careers. “One of the main benefits they offer is availability, simply because we [the group’s practice members] are in the hospital 24/7,” he says. “They also have more experience in dealing with more complex issues, just as do the PAs that are working in our system.”

What about the notion that PAs and nurse practitioners are more skilled or practiced with patient and family communications? One study by Rudy, et al. found that nurse practitioners and PAs were more likely than residents to discuss patients with bedside nurses and to interact with patients’ families.3 Genzink does not find this to be the case in his group’s practice.

 

“That presumption [that PAs are more communicative with families and patients] may have come about simply because as the demands on hospitalists continue to grow and the workload increases, adding the PA to the team means there are more people to do things like that [handle family communications],” he says. “Certainly, in our group, the PAs do lots of patient education, and we talk to patients about end-of-life issues and other difficult matters as well. But that is not delegated to them; in our group, both the PAs and the physicians participate equally in patient and family communication.”

Daily Learning

Hospitalists and PAs also complement each other in the interdisciplinary care team because, “as a general rule, hospitalists love to teach,” says Kislingbury. “They don’t forget that just because you have your PA degree your learning does not stop there. The PA profession is almost like on-the-job training. You are allowed to choose the specialty that you want, and you gain your experience when you enter that [arena], as opposed to an internship or residency, where you first gain experience and then enter the specialty. We so appreciate the ability of the hospitalist to teach because we are learning while doing, on a day-to-day basis. It’s invaluable to have their teaching.” TH

Gretchen Henkel also writes about dealing with difficult families in this issue.

Resources

1. Christmas AB, Reynolds J, Hodges S, et al. Physician extenders impact trauma systems. J Trauma. 2005 May;58(5):917-920.
2. Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2203. Alexandria, Va. Association of Physician Assistant Programs.
3. Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care. 1998 Jul;7(4):267-281.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team—from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Several months ago, a patient with decompensated end-stage liver disease was admitted to the Internal Medicine Hospitalist Service at the University of Texas Medical Branch in Galveston and required a paracentesis. One of the new hospitalist faculty members was taken aback when the physician assistant (PA) on the service volunteered to do the procedure. “He was surprised,” says Karen Kislingbury, PA-C, a member of SHM’s Non-Physician Provider Task Force and a PA with the Internal Medicine Hospitalist Service, “that the scope of practice for the physician assistant included [performing] procedures.”

PAs are not new to the hospital setting, and their inclusion as physician extenders to increase patient access to care will likely increase in the current regulatory environment—especially state-mandated staff/patient ratios and resident work hour limitations. The efficacy of utilizing physician extenders to improve patient care and outcomes has been validated in studies over the past two decades. A recent Journal of Trauma study found statistically significant reductions in floor, ICU, and overall hospital lengths of stay after incorporating physician extenders into their trauma service.1

However, hospitalists unfamiliar with PAs may not understand their colleagues’ roles and scope of practice. As her anecdote illustrated, Kislingbury notes that “although PAs aren’t new to the healthcare delivery system, and physicians have been utilizing us for a long time, our partnership in the unique setting of hospital medicine is kind of new.”

Kislingbury’s colleague Ryan Genzink, PA-C, who works with Hospitalists of West Michigan, a private hospitalists-only group that subcontracts hospitalist services to Spectrum Health of Grand Rapids, Mich., agrees with her assessment.

“There are more and more PAs and [nurse practitioners] working in hospital medicine, and I think there is a lot of curiosity and some apprehension on the part of people who have not worked with these non-physician providers,” says Genzink.

Genzink, also a member of SHM’s Non-Physician Provider Task Force, speculates that the apprehension of physicians who have not worked with PAs may be due to a misunderstanding of the PA’s role. “They’re either underestimating or overestimating exactly what a PA can do or what they are getting when they hire a PA,” he says.

A Short History of the Profession

PA programs officially began in the mid-1960s at Duke University Medical School (Durham, N.C.). Eugene Stead, MD, is credited with developing the concept of the physician assistant as a health professional who would work with physician supervision to extend patient access to care, according to the American Academy of Physician Assistants.

For the first class of PAs in 1965, Dr. Stead selected Navy corpsmen who had received medical training and experience during their service in Vietnam. The curriculum was based on Dr. Stead’s knowledge of fast-track training of physicians during World War II. From this early program, the profession has evolved to more than 130 programs that now adhere to rigorous national accreditation standards set forth by the independent Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA is sponsored by the American Medical Association and the American College of Surgeons, among many other professional medical organizations (www.aapa.org/geninfo1.html).

 

Scope of Practice

Prerequisites to PA programs include two years of college courses in basic and behavioral science, as well as prior experience in healthcare. According to a report generated by the Association of Physician Assistant Programs, most PA students have earned a bachelor’s degree and have an average of 38 months of healthcare experience before being admitted to a PA program.2

The first year of PA education comprises a didactic curriculum with coursework in anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of rotations—typically in family and internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. By the time they graduate (typical PA programs last an average of 26 months), PAs will have completed more than 2,000 hours of supervised clinical practice.

PAs work in all areas of medicine. Although hospital bylaws and state regulations often stipulate the PA’s scope of practice, the major determinant of duties is the supervising physician. The relationship between supervising physician and PA, says Kislingbury, is a collaborative one. Duties are “defined on an individual basis, and they are determined based on our [PAs’] experience, the physicians’ experience with us, and then the nuances of the system and the hospital itself.

“The PA who is hired should know what his or her scope of practice is,” she continues. “By the time they have graduated and obtained their license, they should know what their state allows them to do.”

For instance, according to the American Academy of Physician Assistants, 48 of the 50 states, plus the District of Columbia and [the U.S. Territory of] Guam, authorize PAs to prescribe medications. In California, PA prescriptions are referred to as “written prescription transmittal orders.”

“For the most part,” says Genzink, “the supervising physician determines what the PA is capable of doing, within the guidelines of state law.”

Within Genzink’s hospital medicine group (with which he has been affiliated for five years) the physician and PA roles are very similar.

“We see the same type of patients in a team approach. For instance, it’s not uncommon for one of us to order a test early in the day, and then, when results come back, the other person may be discharging that patient or prescribing other treatments, if necessary,” he explains. “In general, the physicians take care of the more complicated patients, while PAs take care of more routine patients.”

Genzink’s group experience aligns with findings of a 1998 University of Pittsburgh School of Nursing Study, which evaluated provider roles and patient outcomes in an acute care setting.3 Compared with acute care nurse practitioners and PAs, residents in that study tended to care for patients who were older and sicker.

Genzink reports that in his group initial histories and physicals, as well as the consultations, are performed exclusively by the PAs and then the physician takes over for treatment. “Based on the acuity of the patient,” says Genzink, “the physician may be right down there to see the patient immediately.”

Areas for Improvement?

Although the two PAs interviewed for this article report positive experiences working with hospitalists, they admit that some physicians continue to hold misperceptions about the PA’s role in caring for patients.

Kislingbury says that hospitalists could improve their delegation of duties to the PAs and recognize their scope of practice. She admits that delegation duties can be improved through gaining experience. “Although the PA profession has been around for a while, there are a surprising number of institutions that do not utilize physician assistants on the wards in routine rounds and bedside-type care,” says Kislingbury.

 

“I think some of the problems develop when they [physicians] hire a PA and expect to get a physician—and they [don’t],” says Genzink. “The easiest way for me to explain the role is to compare it to a teaching model. All physicians have been through residency programs. They understand the hierarchy that involves training and teaching residents. PAs come out of school ‘green,’ with the assumption that training will go on at the workplace. So, if a physician takes the same stance toward a new PA as they would toward an intern, that is a pretty close comparison.

“You begin by letting PAs or interns do a few simple things, and as they master those, you teach them more,” he continues. “And then, hopefully, over time they’ve been able to master everything that the physician is able to master. [Employing a PA] is a significant investment. And, it takes time. Sometimes, that process can be very easy, depending on the person. Sometimes it can be very slow, and I think that’s sometimes where some of the frustration may come in.”

Genzink adds that in his hospital medicine group, the physicians are familiar with the idea that part of their job as supervising physicians is to train new PAs.

Kislingbury points that out that PAs can also play a role in informing the physician team members about the range of cases they are allowed to treat, thus furthering the collaboration between PAs and hospitalists: “It is merely a matter of educating the team members about what we can and cannot do.”

Accordingly, the SHM Non-Physician Provider Task Force was formed to provide a resource to hospitalists who work with PAs and have questions about scope of practice, reimbursement, and other issues as they pertain to PAs and nurse practitioners. (Visit www.hospitalmedicine.org for more information.) The Task Force is a resource for non-physicians providers, too, offering educational opportunities at SHM meetings, more visibility with the specialty, and a voice for advocacy.

The Positives of the Collaboration

While the PAs report that hospitalists could improve in communicating about their practice roles with PAs, “There are so many things that hospitalists do right!” says Kislingbury. Calling the experience of working with hospitalists a privilege, she says that “where it is a true partnership, we are treated as equals, we are given the responsibility that our experience will allow, and we are truly team members.

“Hospitalists are geared into the efficiencies of the system and the nuances of the hospital. These are subtleties that come with practicing in an area for a long period of time, not just coming in for a month and then leaving and returning,” she says. “Hospitalists know the daily ins and outs, and it is really a pleasure to learn from them.”

Prior to his affiliation with Hospitalists of West Michigan, Genzink was employed directly by a hospital in Grand Rapids. The physicians with whom he now works have been hospitalists almost exclusively throughout their medical careers. “One of the main benefits they offer is availability, simply because we [the group’s practice members] are in the hospital 24/7,” he says. “They also have more experience in dealing with more complex issues, just as do the PAs that are working in our system.”

What about the notion that PAs and nurse practitioners are more skilled or practiced with patient and family communications? One study by Rudy, et al. found that nurse practitioners and PAs were more likely than residents to discuss patients with bedside nurses and to interact with patients’ families.3 Genzink does not find this to be the case in his group’s practice.

 

“That presumption [that PAs are more communicative with families and patients] may have come about simply because as the demands on hospitalists continue to grow and the workload increases, adding the PA to the team means there are more people to do things like that [handle family communications],” he says. “Certainly, in our group, the PAs do lots of patient education, and we talk to patients about end-of-life issues and other difficult matters as well. But that is not delegated to them; in our group, both the PAs and the physicians participate equally in patient and family communication.”

Daily Learning

Hospitalists and PAs also complement each other in the interdisciplinary care team because, “as a general rule, hospitalists love to teach,” says Kislingbury. “They don’t forget that just because you have your PA degree your learning does not stop there. The PA profession is almost like on-the-job training. You are allowed to choose the specialty that you want, and you gain your experience when you enter that [arena], as opposed to an internship or residency, where you first gain experience and then enter the specialty. We so appreciate the ability of the hospitalist to teach because we are learning while doing, on a day-to-day basis. It’s invaluable to have their teaching.” TH

Gretchen Henkel also writes about dealing with difficult families in this issue.

Resources

1. Christmas AB, Reynolds J, Hodges S, et al. Physician extenders impact trauma systems. J Trauma. 2005 May;58(5):917-920.
2. Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2203. Alexandria, Va. Association of Physician Assistant Programs.
3. Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care. 1998 Jul;7(4):267-281.

Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-1700.

Background: Critically ill patients require complex, immediate, high-intensity care, potentially placing them at increased risk of iatrogenic injury. The frequency and nature of adverse events and errors in the modern ICU have not been clearly defined.

Methods: Harvard researchers conducted a prospective, one-year, observational study of a MICU and a CCU at a tertiary care medical center. Adverse events and medical errors were identified by a four-pronged approach: direct 24-hour observation of interns, voluntary incident reporting, a computerized adverse drug event monitoring system, and chart abstraction. Two physicians independently assessed the type, severity, and preventability of the incidents.

Results: A total of 391 patients comprising 1,490 patient-days were observed and included. Twenty percent of all patients suffered an adverse event, 45% of which were preventable and 13% of which were felt to be life-threatening. There were 223 serious errors (those that caused harm or had the potential to cause harm) observed of which 11% were life threatening. Medication adverse events and medication errors accounted for a large proportion of the incidents during the study. Slips and lapses in care were much more common than rule-based (such as using the wrong protocol) or knowledge-based mistakes.

Discussion: Since the Institute of Medicine report in 1999, there has been an increasing focus on patient safety in the inpatient setting. Based on the results of this study and others, it appears the high-intensity, fast-paced nature of critical care places patients at substantial risk for iatrogenic injury. Up to 20% of patients admitted to the ICU in this study suffered an adverse event or a medical error, which translates into 0.8 adverse events and 1.5 serious medical errors per day in a 10-bed ICU.

Because failure to carry out intended plans (usually secondary to slips and lapses on the part of healthcare providers) was the most common cause of adverse events and errors, the authors address possible solutions. They propose employing computerized-order entry, clinical pharmacists in the ICU, closed ICU staffing, “smart” intravenous pumps, and improved teamwork and communication among healthcare providers. Hospitalists often manage critically ill patients and should be aware of the high risk of medical errors and should consider implementing specific systems changes to mitigate the risk.

The Value of Obtaining Blood Cultures in Pneumonia Pts

Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005 Nov;46(5):393-400.

Background: Previous observational studies in patients hospitalized with community-acquired pneumonia (CAP) have shown obtaining blood cultures may have a mortality benefit. This practice has become expert guideline-recommended, the standard of care, as well as a quality marker in the management of CAP. Several recent studies have questioned the utility and cost-effectiveness of this practice.

Methods: Harvard researchers performed a prospective, observational, cohort study of adults admitted to an urban university medical center. Researchers identified patients who had all of the following: clinical CAP, radiographic CAP, and blood cultures at admission. Blood cultures were classified as positive, negative, or contaminated based on previously established criteria. Data were collected on antimicrobial sensitivities, empiric antibiotic choices, and antibiotic changes.

Results: In one year, 414 patients with clinical and radiographic CAP had blood cultures at the time of admission. Twenty-nine of 414 (7%) of patients had true bacteremia while 25 of 414 (6%) had contaminants. Antibiotic therapy was altered in response to blood culture results in 15 of 414 patients (3.6%), of which 11 (2.7%) had therapy narrowed and four (1.0%) had therapy broadened. Of the 11 patients with bacteremia whose therapy was not changed, culture results supported narrowing therapy in eight cases but this was not done.

 

Discussion: This well done prospective observational study adds to a growing body of evidence questioning the utility of routine blood cultures on all patients hospitalized with CAP. The argument traditionally has been made that blood cultures allow clinicians to narrow or broaden antibiotics based on sensitivities. Yet, empiric therapy was broadened in response to bacteremia in only a small fraction of patients (1%) and in only 11 of 19 patients was therapy appropriately narrowed based on the blood cultures. The study did not measure the impact of blood cultures on clinical outcomes, but these striking results reveal that routine blood cultures rarely alter our management of hospitalized patients with CAP.

Further, many have argued obtaining routine blood cultures in CAP can have negative consequences. Blood cultures are relatively costly and time intensive, contaminated blood cultures can lead to repeated testing and increased length of stay, and delays in obtaining blood cultures can delay antibiotic administration, another important quality marker in CAP. For now, it remains the standard of care to obtain blood cultures in these patients, but hospitalists should be aware of the limitations of this practice and consider focusing on other clinical interventions and quality measures in CAP.

A Review Study: A Dyspneic Emergency Patient

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294:944-1956.

Background: Distinguishing CHF from non-cardiac causes of dyspnea is a major challenge for hospitalists and emergency physicians, particularly in patients with a prior history of cardiac disease. Traditionally, clinicians have relied on the history, physical examination, and basic tests (chest X-ray and electrocardiogram) to diagnose CHF, but rapid B-type natriuretic peptide (BNP) testing is now widely incorporated as well.

A previous article in the Rational Clinical Examination series (Can the clinical examination diagnose left-sided heart failure in adults? JAMA. 1997;277(21):1712-1719) found that systolic dysfunction was moderately well predicted by an abnormal apical impulse on physical examination, radiographic cardiomegaly or venous redistribution, or electrocardiographic q waves or left bundle branch block.

Methods: In this review, the authors update and extend previous findings by also assessing the utility of serum BNP testing. The authors identified articles evaluating the diagnostic accuracy of the clinical exam and laboratory testing in diagnosing CHF in patients presenting to the emergency department with undifferentiated dyspnea. The “gold standard” was a clinical diagnosis of CHF made by the treating clinicians after an appropriate diagnostic workup. Summary likelihood ratios (LRs) were calculated using meta-analytic methodology.

Results/discussion: The authors determined that several findings increase the probability of CHF. A prior history of CHF (LR 5.8, CI 4.1-8.0) or myocardial infarction (LR 3.1, 95% CI 2.0-4.9), symptoms of paroxysmal nocturnal dyspnea (LR 2.6, 95% CI 1.5-4.5) and orthopnea (LR 2.2, 95% CI 1.2-3.9) were the most predictive historical factors. On physical examination, the presence of an S3 (LR 11, 95% CI 4.9-25), jugular venous distension (5.1, 95% CI 3.2-7.9), lung rales (LR 2.8, 95% CI 1.9-4.1), and peripheral edema (2.3, 95% CI 1.5-3.7) increased the probability of CHF. In interpreting these results, it is helpful to remember that a likelihood ratio of 2 increases the post-test probability by about 15%, and an LR of 5 increases the post-test probability by about 30%. Thus, a prior history of CHF and presence of an S3 or jugular venous distension are the most useful findings. Interestingly, clinician’s gestalt was equally predictive (LR 4.4, 95% CI 1.8-10.0.)

 

The most useful radiographic findings were venous congestion (LR 12.0, 95% CI 6.8-21) and the presence of cardiomegaly (LR 3.3; 95% CI 2.4-4.7). The single most predictive ECG finding was atrial fibrillation (LR 3.8; 95% CI 2.7-8.8); any abnormality on ECG had an LR of 2.2 (95% CI 1.6-3.1). Serum BNP levels were not more predictive of CHF than the history or physical examination; a BNP of >250 was associated with an LR of 4.6 (95% CI 2.6-8.0).

Few findings markedly decreased the probability of CHF. Here, it is helpful to remember that an LR of 0.5 decreases the post-test probability by about 15%, and an LR of 0.2 decreases the post-test probability by about 30%. With these in mind, the absence of cardiomegaly on CXR significantly changes the post-test probability (LR 0.33; 95% CI 0.23-0.48). A serum BNP level of less than 100pg/ml strongly argues against CHF, with an LR of 0.11 (95% CI 0.07-0.16); this finding lowers the post-test probability of CHF by about 45% compared to the pre-test probability.

In summary, the most useful findings for ruling in CHF in dyspneic emergency department patients were clinical gestalt, a prior history of CHF, findings of an S3 or jugular venous distension, and radiographic findings of venous congestion or cardiomegaly. Absence of radiographic cardiomegaly and a BNP of less than 100pg/ml argue against CHF. These must be interpreted in the context of the clinical pre-test probability of CHF, as none of the findings had likelihood ratios sufficient to be diagnostic of CHF when used individually.

What Should I Wear Today?

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov; 118(11): 1279-1286.

Background: This study addresses the prototypical everyday clinical dilemma: What should I wear to work?

Methods: Patients and visitors to an outpatient Veterans Affairs internal medicine clinic in South Carolina were shown photographs of male and female physicians in four different styles of dress:

1. Professional (male physician wearing white coat with tie, female physician wearing white coat with tailored skirt or trousers);
2. Business (suit and tie for male, tailored trouser or skirt for female);
3. Surgical (surgical scrubs for both male and female): and
4. Casual (jeans and t-shirt or short skirt).

The study was randomized so that male and female respondents viewed photographs of either male or female physicians. Respondents were asked to report how strongly they felt about the importance of their physician’s appearance, and their preference for each style of dress; specifically, respondents were asked which physician was the most trustworthy, which physician they felt most comfortable with for routine examinations and emergencies, and which physician they felt most comfortable discussing psychological, sexual, and social problems with.

Results: Respondents overwhelmingly preferred professional attire for all questions: 76.3% felt most comfortable with a professionally dressed physician for all encounters, with surgical scrubs a distant second (10.2%), ahead of business dress (8.8%). Respondents were also significantly more willing to discuss psychological, sexual, and social problems with a professionally dressed physician. Even for care in an emergency situation, respondents still expressed a significant preference for professional attire over scrubs.

In a logistic regression model, patients who were older, African-American, and had less than a high school education were significantly more likely to prefer professional attire. Interestingly, female respondents who viewed photographs of female physicians placed significantly greater emphasis on physician’s attire than did male respondents.

 

Discussion: The study is clearly subject to caveats, chiefly that it was conducted at a single VA clinic and that only one aspect of the physician-patient encounter was addressed. Undoubtedly, patient’s preferences were influenced by the popular portrayal of physicians on TV shows. Nevertheless, given that hospitalists typically see older patients with whom they are not familiar, the initial clinical encounter may indeed by influenced by something as simple as wearing a white coat.

UA by Nephrologist Versus Hospital-Based Clinical Labs

Tsai JJ, Yeun JY, Kumar VA, Don BR. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005 Nov;46(5):820-829.

Background: Distinguishing the correct cause of acute renal failure is a frequent clinical dilemma for hospitalists, particularly diagnosing acute tubular necrosis (ATN), which is the most common cause of in-hospital acute renal failure. Although urinalysis with microscopy is the first test ordered on noting an abnormal serum creatinine, most hospitalists rely on the results generated by a laboratory technician. Anecdotally, many nephrologists have noted significant differences between urinalysis results performed by technicians and results found by nephrologists.

Methods: This study enrolled 26 patients hospitalized with acute renal failure on whom nephrology consultation was obtained. Urinalysis was performed both by laboratory personnel and a nephrologist (nephrologist A) who was blinded to the patient’s clinical information. Both sets of urinalysis results were independently used by nephrologist A and a second nephrologist (nephrologist B) to arrive at a clinical diagnosis for the patient, without having access to any other clinical information. These diagnoses were compared to the final diagnosis determined by the consulting nephrology service, who themselves did not have access to the diagnosis of either nephrologist A or B.

Results: The influence of having a nephrologist perform and interpret the urinalysis was striking. Nephrologist A was able to correctly diagnose 92.3% of cases based solely on his interpretation of the urinalysis. However, when given only the laboratory report of the urinalysis, both nephrologists were unable to diagnose most cases (23.1% for nephrologist A and 19.2% for nephrologist B). The major difference appeared to be in nephrologist A’s ability to find renal tubular epithelial (RTE) cells and RTE casts, which are pathognomonic of ATN. RTE cells and granular casts were frequently misinterpreted as squamous epithelial cells by laboratory personnel. This was particularly important as 81% of patients in the study had ATN as the primary cause of renal failure. Acanthocytes (dysmorphic red blood cells) were also missed by laboratory personnel in all six patients who were subsequently diagnosed with glomerulonephritis; nephrologist A correctly noted acanthocytes in five of these patients, and arrived at the correct diagnosis in all six patients.

 

Discussion: Microscopic evaluation of urine sediment has become a lost art among physicians, especially since passage of the Clinical Laboratory Improvement Amendments (CLIA) in 1988, which mandated that only CLIA-certified personnel could perform most laboratory tests. While it is probably unrealistic to call for training in microscopic urinalysis for all physicians, hospitalists in particular would benefit from such training, and at the very least should be mindful that laboratory urinalysis results may miss subtle findings that can be invaluable in diagnosing acute renal failure. This study points out the need for greater oversight and training of laboratory personnel, and serves as a reminder to clinicians that laboratory results should not be considered the gold standard. TH

Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-1700.

Background: Critically ill patients require complex, immediate, high-intensity care, potentially placing them at increased risk of iatrogenic injury. The frequency and nature of adverse events and errors in the modern ICU have not been clearly defined.

Methods: Harvard researchers conducted a prospective, one-year, observational study of a MICU and a CCU at a tertiary care medical center. Adverse events and medical errors were identified by a four-pronged approach: direct 24-hour observation of interns, voluntary incident reporting, a computerized adverse drug event monitoring system, and chart abstraction. Two physicians independently assessed the type, severity, and preventability of the incidents.

Results: A total of 391 patients comprising 1,490 patient-days were observed and included. Twenty percent of all patients suffered an adverse event, 45% of which were preventable and 13% of which were felt to be life-threatening. There were 223 serious errors (those that caused harm or had the potential to cause harm) observed of which 11% were life threatening. Medication adverse events and medication errors accounted for a large proportion of the incidents during the study. Slips and lapses in care were much more common than rule-based (such as using the wrong protocol) or knowledge-based mistakes.

Discussion: Since the Institute of Medicine report in 1999, there has been an increasing focus on patient safety in the inpatient setting. Based on the results of this study and others, it appears the high-intensity, fast-paced nature of critical care places patients at substantial risk for iatrogenic injury. Up to 20% of patients admitted to the ICU in this study suffered an adverse event or a medical error, which translates into 0.8 adverse events and 1.5 serious medical errors per day in a 10-bed ICU.

Because failure to carry out intended plans (usually secondary to slips and lapses on the part of healthcare providers) was the most common cause of adverse events and errors, the authors address possible solutions. They propose employing computerized-order entry, clinical pharmacists in the ICU, closed ICU staffing, “smart” intravenous pumps, and improved teamwork and communication among healthcare providers. Hospitalists often manage critically ill patients and should be aware of the high risk of medical errors and should consider implementing specific systems changes to mitigate the risk.

The Value of Obtaining Blood Cultures in Pneumonia Pts

Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005 Nov;46(5):393-400.

Background: Previous observational studies in patients hospitalized with community-acquired pneumonia (CAP) have shown obtaining blood cultures may have a mortality benefit. This practice has become expert guideline-recommended, the standard of care, as well as a quality marker in the management of CAP. Several recent studies have questioned the utility and cost-effectiveness of this practice.

Methods: Harvard researchers performed a prospective, observational, cohort study of adults admitted to an urban university medical center. Researchers identified patients who had all of the following: clinical CAP, radiographic CAP, and blood cultures at admission. Blood cultures were classified as positive, negative, or contaminated based on previously established criteria. Data were collected on antimicrobial sensitivities, empiric antibiotic choices, and antibiotic changes.

Results: In one year, 414 patients with clinical and radiographic CAP had blood cultures at the time of admission. Twenty-nine of 414 (7%) of patients had true bacteremia while 25 of 414 (6%) had contaminants. Antibiotic therapy was altered in response to blood culture results in 15 of 414 patients (3.6%), of which 11 (2.7%) had therapy narrowed and four (1.0%) had therapy broadened. Of the 11 patients with bacteremia whose therapy was not changed, culture results supported narrowing therapy in eight cases but this was not done.

 

Discussion: This well done prospective observational study adds to a growing body of evidence questioning the utility of routine blood cultures on all patients hospitalized with CAP. The argument traditionally has been made that blood cultures allow clinicians to narrow or broaden antibiotics based on sensitivities. Yet, empiric therapy was broadened in response to bacteremia in only a small fraction of patients (1%) and in only 11 of 19 patients was therapy appropriately narrowed based on the blood cultures. The study did not measure the impact of blood cultures on clinical outcomes, but these striking results reveal that routine blood cultures rarely alter our management of hospitalized patients with CAP.

Further, many have argued obtaining routine blood cultures in CAP can have negative consequences. Blood cultures are relatively costly and time intensive, contaminated blood cultures can lead to repeated testing and increased length of stay, and delays in obtaining blood cultures can delay antibiotic administration, another important quality marker in CAP. For now, it remains the standard of care to obtain blood cultures in these patients, but hospitalists should be aware of the limitations of this practice and consider focusing on other clinical interventions and quality measures in CAP.

A Review Study: A Dyspneic Emergency Patient

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294:944-1956.

Background: Distinguishing CHF from non-cardiac causes of dyspnea is a major challenge for hospitalists and emergency physicians, particularly in patients with a prior history of cardiac disease. Traditionally, clinicians have relied on the history, physical examination, and basic tests (chest X-ray and electrocardiogram) to diagnose CHF, but rapid B-type natriuretic peptide (BNP) testing is now widely incorporated as well.

A previous article in the Rational Clinical Examination series (Can the clinical examination diagnose left-sided heart failure in adults? JAMA. 1997;277(21):1712-1719) found that systolic dysfunction was moderately well predicted by an abnormal apical impulse on physical examination, radiographic cardiomegaly or venous redistribution, or electrocardiographic q waves or left bundle branch block.

Methods: In this review, the authors update and extend previous findings by also assessing the utility of serum BNP testing. The authors identified articles evaluating the diagnostic accuracy of the clinical exam and laboratory testing in diagnosing CHF in patients presenting to the emergency department with undifferentiated dyspnea. The “gold standard” was a clinical diagnosis of CHF made by the treating clinicians after an appropriate diagnostic workup. Summary likelihood ratios (LRs) were calculated using meta-analytic methodology.

Results/discussion: The authors determined that several findings increase the probability of CHF. A prior history of CHF (LR 5.8, CI 4.1-8.0) or myocardial infarction (LR 3.1, 95% CI 2.0-4.9), symptoms of paroxysmal nocturnal dyspnea (LR 2.6, 95% CI 1.5-4.5) and orthopnea (LR 2.2, 95% CI 1.2-3.9) were the most predictive historical factors. On physical examination, the presence of an S3 (LR 11, 95% CI 4.9-25), jugular venous distension (5.1, 95% CI 3.2-7.9), lung rales (LR 2.8, 95% CI 1.9-4.1), and peripheral edema (2.3, 95% CI 1.5-3.7) increased the probability of CHF. In interpreting these results, it is helpful to remember that a likelihood ratio of 2 increases the post-test probability by about 15%, and an LR of 5 increases the post-test probability by about 30%. Thus, a prior history of CHF and presence of an S3 or jugular venous distension are the most useful findings. Interestingly, clinician’s gestalt was equally predictive (LR 4.4, 95% CI 1.8-10.0.)

 

The most useful radiographic findings were venous congestion (LR 12.0, 95% CI 6.8-21) and the presence of cardiomegaly (LR 3.3; 95% CI 2.4-4.7). The single most predictive ECG finding was atrial fibrillation (LR 3.8; 95% CI 2.7-8.8); any abnormality on ECG had an LR of 2.2 (95% CI 1.6-3.1). Serum BNP levels were not more predictive of CHF than the history or physical examination; a BNP of >250 was associated with an LR of 4.6 (95% CI 2.6-8.0).

Few findings markedly decreased the probability of CHF. Here, it is helpful to remember that an LR of 0.5 decreases the post-test probability by about 15%, and an LR of 0.2 decreases the post-test probability by about 30%. With these in mind, the absence of cardiomegaly on CXR significantly changes the post-test probability (LR 0.33; 95% CI 0.23-0.48). A serum BNP level of less than 100pg/ml strongly argues against CHF, with an LR of 0.11 (95% CI 0.07-0.16); this finding lowers the post-test probability of CHF by about 45% compared to the pre-test probability.

In summary, the most useful findings for ruling in CHF in dyspneic emergency department patients were clinical gestalt, a prior history of CHF, findings of an S3 or jugular venous distension, and radiographic findings of venous congestion or cardiomegaly. Absence of radiographic cardiomegaly and a BNP of less than 100pg/ml argue against CHF. These must be interpreted in the context of the clinical pre-test probability of CHF, as none of the findings had likelihood ratios sufficient to be diagnostic of CHF when used individually.

What Should I Wear Today?

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov; 118(11): 1279-1286.

Background: This study addresses the prototypical everyday clinical dilemma: What should I wear to work?

Methods: Patients and visitors to an outpatient Veterans Affairs internal medicine clinic in South Carolina were shown photographs of male and female physicians in four different styles of dress:

1. Professional (male physician wearing white coat with tie, female physician wearing white coat with tailored skirt or trousers);
2. Business (suit and tie for male, tailored trouser or skirt for female);
3. Surgical (surgical scrubs for both male and female): and
4. Casual (jeans and t-shirt or short skirt).

The study was randomized so that male and female respondents viewed photographs of either male or female physicians. Respondents were asked to report how strongly they felt about the importance of their physician’s appearance, and their preference for each style of dress; specifically, respondents were asked which physician was the most trustworthy, which physician they felt most comfortable with for routine examinations and emergencies, and which physician they felt most comfortable discussing psychological, sexual, and social problems with.

Results: Respondents overwhelmingly preferred professional attire for all questions: 76.3% felt most comfortable with a professionally dressed physician for all encounters, with surgical scrubs a distant second (10.2%), ahead of business dress (8.8%). Respondents were also significantly more willing to discuss psychological, sexual, and social problems with a professionally dressed physician. Even for care in an emergency situation, respondents still expressed a significant preference for professional attire over scrubs.

In a logistic regression model, patients who were older, African-American, and had less than a high school education were significantly more likely to prefer professional attire. Interestingly, female respondents who viewed photographs of female physicians placed significantly greater emphasis on physician’s attire than did male respondents.

 

Discussion: The study is clearly subject to caveats, chiefly that it was conducted at a single VA clinic and that only one aspect of the physician-patient encounter was addressed. Undoubtedly, patient’s preferences were influenced by the popular portrayal of physicians on TV shows. Nevertheless, given that hospitalists typically see older patients with whom they are not familiar, the initial clinical encounter may indeed by influenced by something as simple as wearing a white coat.

UA by Nephrologist Versus Hospital-Based Clinical Labs

Tsai JJ, Yeun JY, Kumar VA, Don BR. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005 Nov;46(5):820-829.

Background: Distinguishing the correct cause of acute renal failure is a frequent clinical dilemma for hospitalists, particularly diagnosing acute tubular necrosis (ATN), which is the most common cause of in-hospital acute renal failure. Although urinalysis with microscopy is the first test ordered on noting an abnormal serum creatinine, most hospitalists rely on the results generated by a laboratory technician. Anecdotally, many nephrologists have noted significant differences between urinalysis results performed by technicians and results found by nephrologists.

Methods: This study enrolled 26 patients hospitalized with acute renal failure on whom nephrology consultation was obtained. Urinalysis was performed both by laboratory personnel and a nephrologist (nephrologist A) who was blinded to the patient’s clinical information. Both sets of urinalysis results were independently used by nephrologist A and a second nephrologist (nephrologist B) to arrive at a clinical diagnosis for the patient, without having access to any other clinical information. These diagnoses were compared to the final diagnosis determined by the consulting nephrology service, who themselves did not have access to the diagnosis of either nephrologist A or B.

Results: The influence of having a nephrologist perform and interpret the urinalysis was striking. Nephrologist A was able to correctly diagnose 92.3% of cases based solely on his interpretation of the urinalysis. However, when given only the laboratory report of the urinalysis, both nephrologists were unable to diagnose most cases (23.1% for nephrologist A and 19.2% for nephrologist B). The major difference appeared to be in nephrologist A’s ability to find renal tubular epithelial (RTE) cells and RTE casts, which are pathognomonic of ATN. RTE cells and granular casts were frequently misinterpreted as squamous epithelial cells by laboratory personnel. This was particularly important as 81% of patients in the study had ATN as the primary cause of renal failure. Acanthocytes (dysmorphic red blood cells) were also missed by laboratory personnel in all six patients who were subsequently diagnosed with glomerulonephritis; nephrologist A correctly noted acanthocytes in five of these patients, and arrived at the correct diagnosis in all six patients.

 

Discussion: Microscopic evaluation of urine sediment has become a lost art among physicians, especially since passage of the Clinical Laboratory Improvement Amendments (CLIA) in 1988, which mandated that only CLIA-certified personnel could perform most laboratory tests. While it is probably unrealistic to call for training in microscopic urinalysis for all physicians, hospitalists in particular would benefit from such training, and at the very least should be mindful that laboratory urinalysis results may miss subtle findings that can be invaluable in diagnosing acute renal failure. This study points out the need for greater oversight and training of laboratory personnel, and serves as a reminder to clinicians that laboratory results should not be considered the gold standard. TH

Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-1700.

Background: Critically ill patients require complex, immediate, high-intensity care, potentially placing them at increased risk of iatrogenic injury. The frequency and nature of adverse events and errors in the modern ICU have not been clearly defined.

Methods: Harvard researchers conducted a prospective, one-year, observational study of a MICU and a CCU at a tertiary care medical center. Adverse events and medical errors were identified by a four-pronged approach: direct 24-hour observation of interns, voluntary incident reporting, a computerized adverse drug event monitoring system, and chart abstraction. Two physicians independently assessed the type, severity, and preventability of the incidents.

Results: A total of 391 patients comprising 1,490 patient-days were observed and included. Twenty percent of all patients suffered an adverse event, 45% of which were preventable and 13% of which were felt to be life-threatening. There were 223 serious errors (those that caused harm or had the potential to cause harm) observed of which 11% were life threatening. Medication adverse events and medication errors accounted for a large proportion of the incidents during the study. Slips and lapses in care were much more common than rule-based (such as using the wrong protocol) or knowledge-based mistakes.

Discussion: Since the Institute of Medicine report in 1999, there has been an increasing focus on patient safety in the inpatient setting. Based on the results of this study and others, it appears the high-intensity, fast-paced nature of critical care places patients at substantial risk for iatrogenic injury. Up to 20% of patients admitted to the ICU in this study suffered an adverse event or a medical error, which translates into 0.8 adverse events and 1.5 serious medical errors per day in a 10-bed ICU.

Because failure to carry out intended plans (usually secondary to slips and lapses on the part of healthcare providers) was the most common cause of adverse events and errors, the authors address possible solutions. They propose employing computerized-order entry, clinical pharmacists in the ICU, closed ICU staffing, “smart” intravenous pumps, and improved teamwork and communication among healthcare providers. Hospitalists often manage critically ill patients and should be aware of the high risk of medical errors and should consider implementing specific systems changes to mitigate the risk.

The Value of Obtaining Blood Cultures in Pneumonia Pts

Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005 Nov;46(5):393-400.

Background: Previous observational studies in patients hospitalized with community-acquired pneumonia (CAP) have shown obtaining blood cultures may have a mortality benefit. This practice has become expert guideline-recommended, the standard of care, as well as a quality marker in the management of CAP. Several recent studies have questioned the utility and cost-effectiveness of this practice.

Methods: Harvard researchers performed a prospective, observational, cohort study of adults admitted to an urban university medical center. Researchers identified patients who had all of the following: clinical CAP, radiographic CAP, and blood cultures at admission. Blood cultures were classified as positive, negative, or contaminated based on previously established criteria. Data were collected on antimicrobial sensitivities, empiric antibiotic choices, and antibiotic changes.

Results: In one year, 414 patients with clinical and radiographic CAP had blood cultures at the time of admission. Twenty-nine of 414 (7%) of patients had true bacteremia while 25 of 414 (6%) had contaminants. Antibiotic therapy was altered in response to blood culture results in 15 of 414 patients (3.6%), of which 11 (2.7%) had therapy narrowed and four (1.0%) had therapy broadened. Of the 11 patients with bacteremia whose therapy was not changed, culture results supported narrowing therapy in eight cases but this was not done.

 

Discussion: This well done prospective observational study adds to a growing body of evidence questioning the utility of routine blood cultures on all patients hospitalized with CAP. The argument traditionally has been made that blood cultures allow clinicians to narrow or broaden antibiotics based on sensitivities. Yet, empiric therapy was broadened in response to bacteremia in only a small fraction of patients (1%) and in only 11 of 19 patients was therapy appropriately narrowed based on the blood cultures. The study did not measure the impact of blood cultures on clinical outcomes, but these striking results reveal that routine blood cultures rarely alter our management of hospitalized patients with CAP.

Further, many have argued obtaining routine blood cultures in CAP can have negative consequences. Blood cultures are relatively costly and time intensive, contaminated blood cultures can lead to repeated testing and increased length of stay, and delays in obtaining blood cultures can delay antibiotic administration, another important quality marker in CAP. For now, it remains the standard of care to obtain blood cultures in these patients, but hospitalists should be aware of the limitations of this practice and consider focusing on other clinical interventions and quality measures in CAP.

A Review Study: A Dyspneic Emergency Patient

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294:944-1956.

Background: Distinguishing CHF from non-cardiac causes of dyspnea is a major challenge for hospitalists and emergency physicians, particularly in patients with a prior history of cardiac disease. Traditionally, clinicians have relied on the history, physical examination, and basic tests (chest X-ray and electrocardiogram) to diagnose CHF, but rapid B-type natriuretic peptide (BNP) testing is now widely incorporated as well.

A previous article in the Rational Clinical Examination series (Can the clinical examination diagnose left-sided heart failure in adults? JAMA. 1997;277(21):1712-1719) found that systolic dysfunction was moderately well predicted by an abnormal apical impulse on physical examination, radiographic cardiomegaly or venous redistribution, or electrocardiographic q waves or left bundle branch block.

Methods: In this review, the authors update and extend previous findings by also assessing the utility of serum BNP testing. The authors identified articles evaluating the diagnostic accuracy of the clinical exam and laboratory testing in diagnosing CHF in patients presenting to the emergency department with undifferentiated dyspnea. The “gold standard” was a clinical diagnosis of CHF made by the treating clinicians after an appropriate diagnostic workup. Summary likelihood ratios (LRs) were calculated using meta-analytic methodology.

Results/discussion: The authors determined that several findings increase the probability of CHF. A prior history of CHF (LR 5.8, CI 4.1-8.0) or myocardial infarction (LR 3.1, 95% CI 2.0-4.9), symptoms of paroxysmal nocturnal dyspnea (LR 2.6, 95% CI 1.5-4.5) and orthopnea (LR 2.2, 95% CI 1.2-3.9) were the most predictive historical factors. On physical examination, the presence of an S3 (LR 11, 95% CI 4.9-25), jugular venous distension (5.1, 95% CI 3.2-7.9), lung rales (LR 2.8, 95% CI 1.9-4.1), and peripheral edema (2.3, 95% CI 1.5-3.7) increased the probability of CHF. In interpreting these results, it is helpful to remember that a likelihood ratio of 2 increases the post-test probability by about 15%, and an LR of 5 increases the post-test probability by about 30%. Thus, a prior history of CHF and presence of an S3 or jugular venous distension are the most useful findings. Interestingly, clinician’s gestalt was equally predictive (LR 4.4, 95% CI 1.8-10.0.)

 

The most useful radiographic findings were venous congestion (LR 12.0, 95% CI 6.8-21) and the presence of cardiomegaly (LR 3.3; 95% CI 2.4-4.7). The single most predictive ECG finding was atrial fibrillation (LR 3.8; 95% CI 2.7-8.8); any abnormality on ECG had an LR of 2.2 (95% CI 1.6-3.1). Serum BNP levels were not more predictive of CHF than the history or physical examination; a BNP of >250 was associated with an LR of 4.6 (95% CI 2.6-8.0).

Few findings markedly decreased the probability of CHF. Here, it is helpful to remember that an LR of 0.5 decreases the post-test probability by about 15%, and an LR of 0.2 decreases the post-test probability by about 30%. With these in mind, the absence of cardiomegaly on CXR significantly changes the post-test probability (LR 0.33; 95% CI 0.23-0.48). A serum BNP level of less than 100pg/ml strongly argues against CHF, with an LR of 0.11 (95% CI 0.07-0.16); this finding lowers the post-test probability of CHF by about 45% compared to the pre-test probability.

In summary, the most useful findings for ruling in CHF in dyspneic emergency department patients were clinical gestalt, a prior history of CHF, findings of an S3 or jugular venous distension, and radiographic findings of venous congestion or cardiomegaly. Absence of radiographic cardiomegaly and a BNP of less than 100pg/ml argue against CHF. These must be interpreted in the context of the clinical pre-test probability of CHF, as none of the findings had likelihood ratios sufficient to be diagnostic of CHF when used individually.

What Should I Wear Today?

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov; 118(11): 1279-1286.

Background: This study addresses the prototypical everyday clinical dilemma: What should I wear to work?

Methods: Patients and visitors to an outpatient Veterans Affairs internal medicine clinic in South Carolina were shown photographs of male and female physicians in four different styles of dress:

1. Professional (male physician wearing white coat with tie, female physician wearing white coat with tailored skirt or trousers);
2. Business (suit and tie for male, tailored trouser or skirt for female);
3. Surgical (surgical scrubs for both male and female): and
4. Casual (jeans and t-shirt or short skirt).

The study was randomized so that male and female respondents viewed photographs of either male or female physicians. Respondents were asked to report how strongly they felt about the importance of their physician’s appearance, and their preference for each style of dress; specifically, respondents were asked which physician was the most trustworthy, which physician they felt most comfortable with for routine examinations and emergencies, and which physician they felt most comfortable discussing psychological, sexual, and social problems with.

Results: Respondents overwhelmingly preferred professional attire for all questions: 76.3% felt most comfortable with a professionally dressed physician for all encounters, with surgical scrubs a distant second (10.2%), ahead of business dress (8.8%). Respondents were also significantly more willing to discuss psychological, sexual, and social problems with a professionally dressed physician. Even for care in an emergency situation, respondents still expressed a significant preference for professional attire over scrubs.

In a logistic regression model, patients who were older, African-American, and had less than a high school education were significantly more likely to prefer professional attire. Interestingly, female respondents who viewed photographs of female physicians placed significantly greater emphasis on physician’s attire than did male respondents.

 

Discussion: The study is clearly subject to caveats, chiefly that it was conducted at a single VA clinic and that only one aspect of the physician-patient encounter was addressed. Undoubtedly, patient’s preferences were influenced by the popular portrayal of physicians on TV shows. Nevertheless, given that hospitalists typically see older patients with whom they are not familiar, the initial clinical encounter may indeed by influenced by something as simple as wearing a white coat.

UA by Nephrologist Versus Hospital-Based Clinical Labs

Tsai JJ, Yeun JY, Kumar VA, Don BR. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005 Nov;46(5):820-829.

Background: Distinguishing the correct cause of acute renal failure is a frequent clinical dilemma for hospitalists, particularly diagnosing acute tubular necrosis (ATN), which is the most common cause of in-hospital acute renal failure. Although urinalysis with microscopy is the first test ordered on noting an abnormal serum creatinine, most hospitalists rely on the results generated by a laboratory technician. Anecdotally, many nephrologists have noted significant differences between urinalysis results performed by technicians and results found by nephrologists.

Methods: This study enrolled 26 patients hospitalized with acute renal failure on whom nephrology consultation was obtained. Urinalysis was performed both by laboratory personnel and a nephrologist (nephrologist A) who was blinded to the patient’s clinical information. Both sets of urinalysis results were independently used by nephrologist A and a second nephrologist (nephrologist B) to arrive at a clinical diagnosis for the patient, without having access to any other clinical information. These diagnoses were compared to the final diagnosis determined by the consulting nephrology service, who themselves did not have access to the diagnosis of either nephrologist A or B.

Results: The influence of having a nephrologist perform and interpret the urinalysis was striking. Nephrologist A was able to correctly diagnose 92.3% of cases based solely on his interpretation of the urinalysis. However, when given only the laboratory report of the urinalysis, both nephrologists were unable to diagnose most cases (23.1% for nephrologist A and 19.2% for nephrologist B). The major difference appeared to be in nephrologist A’s ability to find renal tubular epithelial (RTE) cells and RTE casts, which are pathognomonic of ATN. RTE cells and granular casts were frequently misinterpreted as squamous epithelial cells by laboratory personnel. This was particularly important as 81% of patients in the study had ATN as the primary cause of renal failure. Acanthocytes (dysmorphic red blood cells) were also missed by laboratory personnel in all six patients who were subsequently diagnosed with glomerulonephritis; nephrologist A correctly noted acanthocytes in five of these patients, and arrived at the correct diagnosis in all six patients.

 

Discussion: Microscopic evaluation of urine sediment has become a lost art among physicians, especially since passage of the Clinical Laboratory Improvement Amendments (CLIA) in 1988, which mandated that only CLIA-certified personnel could perform most laboratory tests. While it is probably unrealistic to call for training in microscopic urinalysis for all physicians, hospitalists in particular would benefit from such training, and at the very least should be mindful that laboratory urinalysis results may miss subtle findings that can be invaluable in diagnosing acute renal failure. This study points out the need for greater oversight and training of laboratory personnel, and serves as a reminder to clinicians that laboratory results should not be considered the gold standard. TH

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

 

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

 

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

 

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

 

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

 

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

 

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

 

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

 

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

 

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Amitriptyline toxicity kills patient

Unknown North Carolina venue

A 26-year-old woman with diabetes saw a psychiatrist to manage her depression. The psychiatrist increased her amitriptyline dosage to 300 mg nightly and over 10 months added:

• alprazolam (unknown dosage, nightly)
  
• quetiapine (400 mg bid)
  
• extended-release venlafaxine (225 mg bid)
  
• and promethazine (100 mg bid).
  

The patient also took insulin for diabetes.

Several weeks later, the woman was found dead in her home. An autopsy revealed amitriptyline toxicity as the cause of death. The medical examiner noted “a much larger concentration of the metabolite nortriptyline in the liver versus the parent drug,” suggesting a metabolism problem, rather than an overdose, caused the toxic build-up.

The patient’s estate claimed that amitriptyline was cardiotoxic at the prescribed dosage and combined with the other medications used and that the patient was not properly monitored.

• A $2.3 million settlement was reached.
  

Fatal cardiac arrest after 2 concomitant antidepressants

Gwinnett County (GA) Superior Court

A 40-year-old woman was under a psychiatrist’s care for anxiety and depression. The psychiatrist continued sertraline, which the woman had been taking, and added nortriptyline. Several weeks after the patient began taking the medications together, she had a fatal cardiac arrest.

The patient’s estate argued that:

• toxic levels of the antidepressants caused her death
  
• sertraline and nortriptyline should not be taken concurrently because one drug inhibits clearance of the other
  
• the psychiatrist should have monitored the patient to make sure sertraline and nortriptyline levels remained normal.
  

The psychiatrist argued that coronary artery disease caused the patient’s death—not the combination of medications.

The medical examiner was unable to say which condition more likely led to the patient’s death.

• The defendant was awarded $3 million. A statutory capitation reduced the award to $1.65 million.
  

Dr. Grant’s observations

As these cases demonstrate, lawsuits against psychiatrists commonly include allegations of preventable prescribing missteps and drug-drug interactions^{Off-label prescribing: 7 steps for safer, more effective treatment”).
When a patient is taking multiple medications, interactions can inhibit drug metabolism and render normal doses excessive.5 When prescribing drugs known to have adverse effects with excessive dosing, such as tricyclic antidepressants and lithium, failing to monitor serum levels could be considered malpractice. In fact, the courts view actions such as prescribing doses that exceed FDA recommendations or failing to monitor levels as prima facie evidence of negligence, requiring the psychiatrist to prove otherwise.}

Amitriptyline and nortriptyline have shown cardiac toxicity in overdose,⁶ and their serum levels increase when used with other antidepressants.^7,8 Standard of care dictates serum level monitoring particularly when you use tricyclics:

• in doses higher than recommended by the FDA (300 mg/d for amitriptyline, 150 mg/d for nortriptyline)
  
• with other drugs that affect their metabolism.⁹
  

You cannot rely on pharmacy computer programs to catch potentially important drug-drug interactions. One study found that even among pharmacies with such programs, one-third of pharmacists filled prescriptions for a dangerous medication combination.¹⁰

Box

How to prevent fatal errors. Don’t shy away from using medications that require serum level monitoring. Anticipating and monitoring drug-drug interactions becomes second nature once you’ve used these medications frequently. Plus, patients benefit from a greater array of safe and effective treatment options.

The following strategies can help you avoid mistakes and malpractice claims.^1,11

Clinical practice. Obtain a comprehensive patient history and necessary examinations before prescribing medications. See patients at clinically appropriate intervals.

Ask the patient about other medications he or she is taking, including over-the-counter medications, herbal remedies, and dietary supplements. Remind the patient to report changes in medications or new medications prescribed by another physician.

Put in place a process to obtain appropriate baseline laboratory testing and to ensure that follow-up testing is completed and reviewed. Monitoring lab results becomes particularly important in cases—such as these two—when escalating levels of certain medications can cause adverse effects.

 

Communicate with the patient’s other physicians about all the medications that are being prescribed to him and about signs, symptoms, and responses to the medications.

Educate yourself by participating in continuing education programs, discussions with colleagues, and through relevant literature. Review drug manufacturer alerts.

Patient education. Educate patients about medication instructions, including the dosage and frequency, ways to identify side effects, and what to do in the event of side effects or a bad reaction. Get informed consent.

Be aware of and inform the patient about potentially lethal side effects of misusing or abusing certain medications. Address the use of street drugs and how they interact with prescription medications; make appropriate treatment assessments and referrals for addiction and dependence issues.

Documentation. Keep thorough records of medications prescribed: dosage, amount, directions for taking them, and other instructions to the patient. Document results of laboratory testing and any decisions you make based on medication serum levels.

When using polypharmacy that increases the risk of adverse interactions, document a clear rationale in patients’ charts.

Amitriptyline toxicity kills patient

Unknown North Carolina venue

A 26-year-old woman with diabetes saw a psychiatrist to manage her depression. The psychiatrist increased her amitriptyline dosage to 300 mg nightly and over 10 months added:

• alprazolam (unknown dosage, nightly)
  
• quetiapine (400 mg bid)
  
• extended-release venlafaxine (225 mg bid)
  
• and promethazine (100 mg bid).
  

The patient also took insulin for diabetes.

Several weeks later, the woman was found dead in her home. An autopsy revealed amitriptyline toxicity as the cause of death. The medical examiner noted “a much larger concentration of the metabolite nortriptyline in the liver versus the parent drug,” suggesting a metabolism problem, rather than an overdose, caused the toxic build-up.

The patient’s estate claimed that amitriptyline was cardiotoxic at the prescribed dosage and combined with the other medications used and that the patient was not properly monitored.

• A $2.3 million settlement was reached.
  

Fatal cardiac arrest after 2 concomitant antidepressants

Gwinnett County (GA) Superior Court

A 40-year-old woman was under a psychiatrist’s care for anxiety and depression. The psychiatrist continued sertraline, which the woman had been taking, and added nortriptyline. Several weeks after the patient began taking the medications together, she had a fatal cardiac arrest.

The patient’s estate argued that:

• toxic levels of the antidepressants caused her death
  
• sertraline and nortriptyline should not be taken concurrently because one drug inhibits clearance of the other
  
• the psychiatrist should have monitored the patient to make sure sertraline and nortriptyline levels remained normal.
  

The psychiatrist argued that coronary artery disease caused the patient’s death—not the combination of medications.

The medical examiner was unable to say which condition more likely led to the patient’s death.

• The defendant was awarded $3 million. A statutory capitation reduced the award to $1.65 million.
  

Dr. Grant’s observations

As these cases demonstrate, lawsuits against psychiatrists commonly include allegations of preventable prescribing missteps and drug-drug interactions^{Off-label prescribing: 7 steps for safer, more effective treatment”).
When a patient is taking multiple medications, interactions can inhibit drug metabolism and render normal doses excessive.5 When prescribing drugs known to have adverse effects with excessive dosing, such as tricyclic antidepressants and lithium, failing to monitor serum levels could be considered malpractice. In fact, the courts view actions such as prescribing doses that exceed FDA recommendations or failing to monitor levels as prima facie evidence of negligence, requiring the psychiatrist to prove otherwise.}

Amitriptyline and nortriptyline have shown cardiac toxicity in overdose,⁶ and their serum levels increase when used with other antidepressants.^7,8 Standard of care dictates serum level monitoring particularly when you use tricyclics:

• in doses higher than recommended by the FDA (300 mg/d for amitriptyline, 150 mg/d for nortriptyline)
  
• with other drugs that affect their metabolism.⁹
  

You cannot rely on pharmacy computer programs to catch potentially important drug-drug interactions. One study found that even among pharmacies with such programs, one-third of pharmacists filled prescriptions for a dangerous medication combination.¹⁰

Box

How to prevent fatal errors. Don’t shy away from using medications that require serum level monitoring. Anticipating and monitoring drug-drug interactions becomes second nature once you’ve used these medications frequently. Plus, patients benefit from a greater array of safe and effective treatment options.

The following strategies can help you avoid mistakes and malpractice claims.^1,11

Clinical practice. Obtain a comprehensive patient history and necessary examinations before prescribing medications. See patients at clinically appropriate intervals.

Ask the patient about other medications he or she is taking, including over-the-counter medications, herbal remedies, and dietary supplements. Remind the patient to report changes in medications or new medications prescribed by another physician.

Put in place a process to obtain appropriate baseline laboratory testing and to ensure that follow-up testing is completed and reviewed. Monitoring lab results becomes particularly important in cases—such as these two—when escalating levels of certain medications can cause adverse effects.

 

Communicate with the patient’s other physicians about all the medications that are being prescribed to him and about signs, symptoms, and responses to the medications.

Educate yourself by participating in continuing education programs, discussions with colleagues, and through relevant literature. Review drug manufacturer alerts.

Patient education. Educate patients about medication instructions, including the dosage and frequency, ways to identify side effects, and what to do in the event of side effects or a bad reaction. Get informed consent.

Be aware of and inform the patient about potentially lethal side effects of misusing or abusing certain medications. Address the use of street drugs and how they interact with prescription medications; make appropriate treatment assessments and referrals for addiction and dependence issues.

Documentation. Keep thorough records of medications prescribed: dosage, amount, directions for taking them, and other instructions to the patient. Document results of laboratory testing and any decisions you make based on medication serum levels.

When using polypharmacy that increases the risk of adverse interactions, document a clear rationale in patients’ charts.

Amitriptyline toxicity kills patient

Unknown North Carolina venue

A 26-year-old woman with diabetes saw a psychiatrist to manage her depression. The psychiatrist increased her amitriptyline dosage to 300 mg nightly and over 10 months added:

• alprazolam (unknown dosage, nightly)
  
• quetiapine (400 mg bid)
  
• extended-release venlafaxine (225 mg bid)
  
• and promethazine (100 mg bid).
  

The patient also took insulin for diabetes.

Several weeks later, the woman was found dead in her home. An autopsy revealed amitriptyline toxicity as the cause of death. The medical examiner noted “a much larger concentration of the metabolite nortriptyline in the liver versus the parent drug,” suggesting a metabolism problem, rather than an overdose, caused the toxic build-up.

The patient’s estate claimed that amitriptyline was cardiotoxic at the prescribed dosage and combined with the other medications used and that the patient was not properly monitored.

• A $2.3 million settlement was reached.
  

Fatal cardiac arrest after 2 concomitant antidepressants

Gwinnett County (GA) Superior Court

A 40-year-old woman was under a psychiatrist’s care for anxiety and depression. The psychiatrist continued sertraline, which the woman had been taking, and added nortriptyline. Several weeks after the patient began taking the medications together, she had a fatal cardiac arrest.

The patient’s estate argued that:

• toxic levels of the antidepressants caused her death
  
• sertraline and nortriptyline should not be taken concurrently because one drug inhibits clearance of the other
  
• the psychiatrist should have monitored the patient to make sure sertraline and nortriptyline levels remained normal.
  

The psychiatrist argued that coronary artery disease caused the patient’s death—not the combination of medications.

The medical examiner was unable to say which condition more likely led to the patient’s death.

• The defendant was awarded $3 million. A statutory capitation reduced the award to $1.65 million.
  

Dr. Grant’s observations

As these cases demonstrate, lawsuits against psychiatrists commonly include allegations of preventable prescribing missteps and drug-drug interactions^{Off-label prescribing: 7 steps for safer, more effective treatment”).
When a patient is taking multiple medications, interactions can inhibit drug metabolism and render normal doses excessive.5 When prescribing drugs known to have adverse effects with excessive dosing, such as tricyclic antidepressants and lithium, failing to monitor serum levels could be considered malpractice. In fact, the courts view actions such as prescribing doses that exceed FDA recommendations or failing to monitor levels as prima facie evidence of negligence, requiring the psychiatrist to prove otherwise.}

Amitriptyline and nortriptyline have shown cardiac toxicity in overdose,⁶ and their serum levels increase when used with other antidepressants.^7,8 Standard of care dictates serum level monitoring particularly when you use tricyclics:

• in doses higher than recommended by the FDA (300 mg/d for amitriptyline, 150 mg/d for nortriptyline)
  
• with other drugs that affect their metabolism.⁹
  

You cannot rely on pharmacy computer programs to catch potentially important drug-drug interactions. One study found that even among pharmacies with such programs, one-third of pharmacists filled prescriptions for a dangerous medication combination.¹⁰

Box

How to prevent fatal errors. Don’t shy away from using medications that require serum level monitoring. Anticipating and monitoring drug-drug interactions becomes second nature once you’ve used these medications frequently. Plus, patients benefit from a greater array of safe and effective treatment options.

The following strategies can help you avoid mistakes and malpractice claims.^1,11

Clinical practice. Obtain a comprehensive patient history and necessary examinations before prescribing medications. See patients at clinically appropriate intervals.

Ask the patient about other medications he or she is taking, including over-the-counter medications, herbal remedies, and dietary supplements. Remind the patient to report changes in medications or new medications prescribed by another physician.

Put in place a process to obtain appropriate baseline laboratory testing and to ensure that follow-up testing is completed and reviewed. Monitoring lab results becomes particularly important in cases—such as these two—when escalating levels of certain medications can cause adverse effects.

 

Communicate with the patient’s other physicians about all the medications that are being prescribed to him and about signs, symptoms, and responses to the medications.

Educate yourself by participating in continuing education programs, discussions with colleagues, and through relevant literature. Review drug manufacturer alerts.

Patient education. Educate patients about medication instructions, including the dosage and frequency, ways to identify side effects, and what to do in the event of side effects or a bad reaction. Get informed consent.

Be aware of and inform the patient about potentially lethal side effects of misusing or abusing certain medications. Address the use of street drugs and how they interact with prescription medications; make appropriate treatment assessments and referrals for addiction and dependence issues.

Documentation. Keep thorough records of medications prescribed: dosage, amount, directions for taking them, and other instructions to the patient. Document results of laboratory testing and any decisions you make based on medication serum levels.

When using polypharmacy that increases the risk of adverse interactions, document a clear rationale in patients’ charts.

Benefits of Cardiac Resynchronization

By A. Rudmann, MD

Cleland J, Daubert J, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

A quarter to a third of patients with CHF have left or right bundle branch block, in which one side of the heart depolarizes and contracts before the other. Such electro-mechanical dyssynchrony is associated with decreased ejection fraction (EF), decreased cardiac output, and worse symptoms. A new pacemaker technology—called cardiac resynchronization therapy (CRT)—is a technically difficult procedure that involves placing a lead through the coronary sinus to the left side of the heart, re-establishing electro-mechanical synchrony. CRT improves EF and CHF symptoms, but its effect on mortality has been unknown.

In this unblinded trial funded and aided by Medtronic (a CRT device manufacturer) patients with class III-IV CHF despite standard medical therapy, ejection fraction <35%, and QRS >120 msec were randomized to CRT plus medical therapy or medical therapy alone. Patients with a major cardiovascular event in the preceding six weeks, conventional indication for pacemaker or defibrillator, continuous intravenous therapy for CHF, or atrial arrhythmia were excluded.

Eight-hundred-thirteen patients were followed for a mean of 2.5 years. The primary endpoint (a composite of death from any cause and first unplanned hospitalization for a major cardiovascular event) was reached by 39% of patients in the CRT arm versus 55% in the control arm. Death was also lower in the CRT group (20% versus 30%). Both outcomes were highly statistically significant. Other benefits of CRT included reduced hospitalization for worsening CHF (18% versus 33%), less severe symptoms, better quality of life, and higher left ventricular ejection fraction. Twelve percent of patients required more than one attempt to successfully insert the CRT device.

This study reports significant benefits for CRT added to medical therapy in patients with moderate-to-severe CHF, low EF, and cardiac dyssynchrony. The results are consistent with reported hemodynamic benefits of CRT. Limitations of the study include the unblinded methodology and close participation of the study sponsor in conducting the trial. Both raise questions about potential bias. Until other studies are available, clinicians should decide whether CRT is appropriate for individual patients. The cost effectiveness of CRT is not known.

Handoffs Finally Get Attention

By A. Rudmann, MD

Solet D, Norvell J, Rutan G, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099.

Handoffs involve the transfer of patient care responsibility from one clinician to another. In non-medical industries, analogous situations are known to be error-prone and have received substantial attention. However, despite the six-year-old Institute of Medicine study implicating poor communication as a major contributor to preventable deaths in U.S. hospitals, surprisingly little attention has been paid to handoffs by the medical community. A notable exception is AHRQ’s (the Agency for Healthcare Research and Quality) Web Morbidity and Mortality Rounds, which has highlighted the significance of poor communication among clinicians.

This article evaluates current handoff practices of the Indiana University School of Medicine (Indianapolis) internal medicine residency program. Major findings include significant variability in preparation, content, and method of handoffs across their four-hospital system. Barriers to effective handoff communication include lack of privacy, social hierarchy, language issues, lack of direct communication, inefficiency, and lack of formal education.

The authors propose Essential Elements for Successful Handoffs, including the following content items: complete team information, complete patient identification, brief history of present illness, active problems and past medical history, active medications, allergies, venous access status and contingencies, code status, pertinent lab data, concerns for the next 18-24 hours, long-term plans, and psychosocial concerns. Regarding process, the authors recommend both verbal and written communication routinely and bedside handoffs for high-risk patients. Additionally, they advise a formal handoff curriculum for residents, including both didactic instruction and attending role modeling.

 

While this may seem a tall order, the new 2006 National Patient Safety Goals now address handoff quality. As of January 1, JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requires all accredited institutions to perform handoffs that are both interactive (at least offering the opportunity to interact) and appropriately informative with up-to-date clinical information about diagnoses and treatments, stability, and recent or anticipated changes. All clinicians should evaluate the quality of handoffs in their own practices and make improvements as necessary. This article offers good suggestions on where to start.

The Use of Systemic Steroids for COPD

By A. Rudmann, MD

Niewoehner D, Erbland M, Deupree R, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340:1941-1947.

Systemic steroids are commonly prescribed for COPD exacerbation, despite adverse side effects including hyperglycemia, infections and osteoporosis. This randomized, double-blind, controlled trial conducted by the U.S. Department of Veterans Affairs (VA) compared two- and eight-week steroid regimens to placebo in patients also receiving broad spectrum antibiotics for seven days, inhaled beta-agonists, inhaled ipratropium bromide, and inhaled Triamcinolone Acetonide starting day four.

The steroid arms received methylprednisolone 125 mg every six hours for three days, then oral prednisone was tapered gradually from 60 mg over two or eight weeks. Inclusion criteria were clinical diagnosis of COPD exacerbation, age >50 years, >30 pack years of smoking, and either an FEV1 <1.5 or inability to undergo spirometry because of severe dyspnea. Patients with asthma, systemic steroid use in the preceding 30 days, and prognosis of less than one year were excluded.

In all, 1,870 patients were screened to enroll 271 patients who were followed for 182 days. Fifty percent of screened patients were ineligible due to recent steroid use. Systemic steroid treatment significantly reduced treatment failure at 30 days (23% versus 33%) and 90 days (37% versus 48%), but not at 182 days (51% versus 54%). Treatment failure was defined as death from any cause, mechanical ventilation, readmission for COPD, or intensification of pharmacologic therapy—which accounted for 70% of treatment failures at 30 days, 62% at 90 days, and 58% at 182 days. Seventy-five percent of the time this involved initiation of open-label systemic steroids. Two- and eight-week steroid regimens were equally efficacious. Steroid therapy reduced LOS from 9.7 to 8.5 days and improved FEV1 by a maximum of 0.1 L after one day. Mortality was not affected. Hyperglycemia was more common in the steroid groups (15% vs. 4%). Subgroup analysis showed that patients previously hospitalized benefited most from steroid therapy.

This study helps define the benefits and risks of systemic steroid therapy in COPD exacerbation. It reduces treatment failure rates at one and three months and reduces LOS, but increases hyperglycemia in patients receiving inhaled corticosteroids and other COPD treatments. About half of patients in the placebo arm required intensification of treatment, usually initiation of systemic steroid therapy; the other half averted systemic steroid therapy over six months of follow-up. Overall, this study suggests a rationale for deferring or limiting systemic steroid therapy in those patients without prior hospitalization for COPD and those at high risk for hyperglycemia.

Antibiotics for Atypical Coverage in Pneumonia Patients

By Valerie J. Lang, MD

Shefet D, Robenshtok E, Paul M, et al. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med. 2005:165:1992-2000.

Most guidelines recommend that inpatients with community-acquired pneumonia receive antibiotics that cover atypical organisms, though it is rare that an atypical organism causes pneumonia severe enough to require hospitalization. This review of 24 trials compared antibiotic regimens with and without atypical coverage in a total of 5,015 inpatients with community-acquired pneumonia. Atypical coverage was provided by quinolones or macrolides, and arms without atypical coverage included a wide variety of beta-lactam regimens. There was no difference in overall 30-day mortality with or without atypical coverage (RR 1.13 [95% CI, 0.82-1.54]).

 

For the outcome of clinical failure, there was a trend toward advantage in the quinolone monotherapy arms (RR, 0.89[95% CI, 0.77-1.02]), with a disadvantage in the macrolide monotherapy arms (RR, 1.17 [95% CI, 0.77-1.77]). However, when the studies with unclear or inadequate allocation concealment or allocation generation were excluded, the trend virtually resolved (RR, 0.99 [95%CI, 0.82-1.19]).

For the patients with documented atypical pathogens, there was a trend in favor of atypical coverage (RR, 0.52 [95% CI, 0.24-1.10]). This was significant for the subset of 43 patients with documented Legionella species, (RR, 0.17 [95% CI, 0.05-0.63]). Notably, there was no significant difference in results for different age groups overall.

Although these results support the authors’ conclusion that using antibiotics with or without atypical coverage achieve similar outcomes (except in the rare cases of Legionella species infections), most of the studies used treatment arms that are not in line with current guidelines for the treatment of community-acquired pneumonia in inpatients. Other outcomes of interest to hospitalists (duration of intravenous therapy and length of stay) were not addressed. None of the studies compared a drug without atypical coverage (e.g., ceftriaxone) with the same drug plus another with atypical coverage (e.g., ceftriaxone plus azithromycin).

While guidelines still call for atypical coverage, the results of this review may provide support for hospitalists when treating patients with multiple drug allergies or intolerances who cannot be provided atypical coverage without significant side effects.

In-Home Hospital Care for Seniors

By Valerie J. Lang, MD

Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005:143(11):798-808.

Hospitalists are acutely aware of the hazards of hospitalization for older patients, and several models of providing hospital-level care in patients’ homes have been explored in other countries. This study evaluated a hospital-at-home program which provided acute, hospital-level care to patients ≥65-year-old in three U.S. cities. All patients required hospitalization and had one of the following diagnoses: community acquired pneumonia, CHF exacerbation, COPD exacerbation, or cellulitis. Most of the patients were admitted directly from the emergency department and were never admitted to the hospital.

The hospital-at-home program provided the following services: 1) at least eight-24 hours of continuous, one-on-one nursing; 2) intermittent nursing visits at least daily after continuous nursing was no longer required; 3) at least daily home visits and 24-hour availability by a hospital-at-home physician; 4) durable medical equipment; 5) skilled therapies and pharmacy support; 6) home radiology and ECG; and 7) intravenous fluids, antibiotics, other medications, oxygen, and other respiratory therapies. Patients were referred back to their primary care physicians after discharge from the hospital-at-home stay.

The study consisted of an observation phase followed by an intervention phase for comparison. The results show that the process of providing hospital-level care at home was feasible. Nurses arrived at patients’ homes within a mean of 20 minutes and provided a mean of 16.9 hours (range 0-71 hours) of continuous care, with a mean of 1.4 visits per day (range 0-5.3) after that. Physicians evaluated patients in the homes within a mean of 1.8 hours (range 0-4.5 hours) and provided a mean of 1.5 visits per day (range 0-5.3). There was variability among the sites for some measures. For example, oxygen was delivered to the home within an average of 0.6 or 0.7 hours at two sites, but within an average of 3.3 hours at the third site.

The intervention group had significantly less incident delirium (OR 0.26 [95% CI, 0.12-0.57]), less sedative medication use (OR 0.49 [95%CI, 0.30-0.81]), less use of chemical restraints (2% versus 7%; p=0.014), fewer critical complications (0% versus 6%; p≤0.001), and fewer deaths (0% versus 3%; p=0.050). Mean length of stay in the intervention group was 3.2 days vs. 4.9 days in the observation group (p=0.004). Mean costs were lower in the hospital-at-home group than the hospitalized group ($5,081 versus $7,480; p≤0.001).

 

There were important limitations to the study. Follow-up data was missing on a substantial number of patients (37% of observation group and 28% of intervention group). The 85 patients who were eligible but did not receive hospital-at-home care (either because they declined or the program wasn’t open for admissions from 10 p.m. to 6 a.m.) were combined with the 84 patients who did receive it under intention-to-treat, so the effects of the intervention may be underestimated.

Despite the limitations of the data, the findings of less delirium, sedative use, and chemical restraint use in the hospital-at-home group ring true, as patients were not subjected to the 24-hour noise, 4 a.m. blood draws, and unfamiliar surroundings that promote delirium, insomnia, and agitation in the hospital. Because delirium is common, difficult to prevent, and associated with longer lengths of stay, increased complications, and lower levels of functioning on discharge, the hospital-at-home model is worth studying further. If further evidence can be obtained to support this model, it may be worth pursuing in communities where there are adequate home care resources. Additionally, it may provide a new niche for hospitalists: the “Home Hospitalist.” TH

Benefits of Cardiac Resynchronization

By A. Rudmann, MD

Cleland J, Daubert J, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

A quarter to a third of patients with CHF have left or right bundle branch block, in which one side of the heart depolarizes and contracts before the other. Such electro-mechanical dyssynchrony is associated with decreased ejection fraction (EF), decreased cardiac output, and worse symptoms. A new pacemaker technology—called cardiac resynchronization therapy (CRT)—is a technically difficult procedure that involves placing a lead through the coronary sinus to the left side of the heart, re-establishing electro-mechanical synchrony. CRT improves EF and CHF symptoms, but its effect on mortality has been unknown.

In this unblinded trial funded and aided by Medtronic (a CRT device manufacturer) patients with class III-IV CHF despite standard medical therapy, ejection fraction <35%, and QRS >120 msec were randomized to CRT plus medical therapy or medical therapy alone. Patients with a major cardiovascular event in the preceding six weeks, conventional indication for pacemaker or defibrillator, continuous intravenous therapy for CHF, or atrial arrhythmia were excluded.

Eight-hundred-thirteen patients were followed for a mean of 2.5 years. The primary endpoint (a composite of death from any cause and first unplanned hospitalization for a major cardiovascular event) was reached by 39% of patients in the CRT arm versus 55% in the control arm. Death was also lower in the CRT group (20% versus 30%). Both outcomes were highly statistically significant. Other benefits of CRT included reduced hospitalization for worsening CHF (18% versus 33%), less severe symptoms, better quality of life, and higher left ventricular ejection fraction. Twelve percent of patients required more than one attempt to successfully insert the CRT device.

This study reports significant benefits for CRT added to medical therapy in patients with moderate-to-severe CHF, low EF, and cardiac dyssynchrony. The results are consistent with reported hemodynamic benefits of CRT. Limitations of the study include the unblinded methodology and close participation of the study sponsor in conducting the trial. Both raise questions about potential bias. Until other studies are available, clinicians should decide whether CRT is appropriate for individual patients. The cost effectiveness of CRT is not known.

Handoffs Finally Get Attention

By A. Rudmann, MD

Solet D, Norvell J, Rutan G, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099.

Handoffs involve the transfer of patient care responsibility from one clinician to another. In non-medical industries, analogous situations are known to be error-prone and have received substantial attention. However, despite the six-year-old Institute of Medicine study implicating poor communication as a major contributor to preventable deaths in U.S. hospitals, surprisingly little attention has been paid to handoffs by the medical community. A notable exception is AHRQ’s (the Agency for Healthcare Research and Quality) Web Morbidity and Mortality Rounds, which has highlighted the significance of poor communication among clinicians.

This article evaluates current handoff practices of the Indiana University School of Medicine (Indianapolis) internal medicine residency program. Major findings include significant variability in preparation, content, and method of handoffs across their four-hospital system. Barriers to effective handoff communication include lack of privacy, social hierarchy, language issues, lack of direct communication, inefficiency, and lack of formal education.

The authors propose Essential Elements for Successful Handoffs, including the following content items: complete team information, complete patient identification, brief history of present illness, active problems and past medical history, active medications, allergies, venous access status and contingencies, code status, pertinent lab data, concerns for the next 18-24 hours, long-term plans, and psychosocial concerns. Regarding process, the authors recommend both verbal and written communication routinely and bedside handoffs for high-risk patients. Additionally, they advise a formal handoff curriculum for residents, including both didactic instruction and attending role modeling.

 

While this may seem a tall order, the new 2006 National Patient Safety Goals now address handoff quality. As of January 1, JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requires all accredited institutions to perform handoffs that are both interactive (at least offering the opportunity to interact) and appropriately informative with up-to-date clinical information about diagnoses and treatments, stability, and recent or anticipated changes. All clinicians should evaluate the quality of handoffs in their own practices and make improvements as necessary. This article offers good suggestions on where to start.

The Use of Systemic Steroids for COPD

By A. Rudmann, MD

Niewoehner D, Erbland M, Deupree R, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340:1941-1947.

Systemic steroids are commonly prescribed for COPD exacerbation, despite adverse side effects including hyperglycemia, infections and osteoporosis. This randomized, double-blind, controlled trial conducted by the U.S. Department of Veterans Affairs (VA) compared two- and eight-week steroid regimens to placebo in patients also receiving broad spectrum antibiotics for seven days, inhaled beta-agonists, inhaled ipratropium bromide, and inhaled Triamcinolone Acetonide starting day four.

The steroid arms received methylprednisolone 125 mg every six hours for three days, then oral prednisone was tapered gradually from 60 mg over two or eight weeks. Inclusion criteria were clinical diagnosis of COPD exacerbation, age >50 years, >30 pack years of smoking, and either an FEV1 <1.5 or inability to undergo spirometry because of severe dyspnea. Patients with asthma, systemic steroid use in the preceding 30 days, and prognosis of less than one year were excluded.

In all, 1,870 patients were screened to enroll 271 patients who were followed for 182 days. Fifty percent of screened patients were ineligible due to recent steroid use. Systemic steroid treatment significantly reduced treatment failure at 30 days (23% versus 33%) and 90 days (37% versus 48%), but not at 182 days (51% versus 54%). Treatment failure was defined as death from any cause, mechanical ventilation, readmission for COPD, or intensification of pharmacologic therapy—which accounted for 70% of treatment failures at 30 days, 62% at 90 days, and 58% at 182 days. Seventy-five percent of the time this involved initiation of open-label systemic steroids. Two- and eight-week steroid regimens were equally efficacious. Steroid therapy reduced LOS from 9.7 to 8.5 days and improved FEV1 by a maximum of 0.1 L after one day. Mortality was not affected. Hyperglycemia was more common in the steroid groups (15% vs. 4%). Subgroup analysis showed that patients previously hospitalized benefited most from steroid therapy.

This study helps define the benefits and risks of systemic steroid therapy in COPD exacerbation. It reduces treatment failure rates at one and three months and reduces LOS, but increases hyperglycemia in patients receiving inhaled corticosteroids and other COPD treatments. About half of patients in the placebo arm required intensification of treatment, usually initiation of systemic steroid therapy; the other half averted systemic steroid therapy over six months of follow-up. Overall, this study suggests a rationale for deferring or limiting systemic steroid therapy in those patients without prior hospitalization for COPD and those at high risk for hyperglycemia.

Antibiotics for Atypical Coverage in Pneumonia Patients

By Valerie J. Lang, MD

Shefet D, Robenshtok E, Paul M, et al. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med. 2005:165:1992-2000.

Most guidelines recommend that inpatients with community-acquired pneumonia receive antibiotics that cover atypical organisms, though it is rare that an atypical organism causes pneumonia severe enough to require hospitalization. This review of 24 trials compared antibiotic regimens with and without atypical coverage in a total of 5,015 inpatients with community-acquired pneumonia. Atypical coverage was provided by quinolones or macrolides, and arms without atypical coverage included a wide variety of beta-lactam regimens. There was no difference in overall 30-day mortality with or without atypical coverage (RR 1.13 [95% CI, 0.82-1.54]).

 

For the outcome of clinical failure, there was a trend toward advantage in the quinolone monotherapy arms (RR, 0.89[95% CI, 0.77-1.02]), with a disadvantage in the macrolide monotherapy arms (RR, 1.17 [95% CI, 0.77-1.77]). However, when the studies with unclear or inadequate allocation concealment or allocation generation were excluded, the trend virtually resolved (RR, 0.99 [95%CI, 0.82-1.19]).

For the patients with documented atypical pathogens, there was a trend in favor of atypical coverage (RR, 0.52 [95% CI, 0.24-1.10]). This was significant for the subset of 43 patients with documented Legionella species, (RR, 0.17 [95% CI, 0.05-0.63]). Notably, there was no significant difference in results for different age groups overall.

Although these results support the authors’ conclusion that using antibiotics with or without atypical coverage achieve similar outcomes (except in the rare cases of Legionella species infections), most of the studies used treatment arms that are not in line with current guidelines for the treatment of community-acquired pneumonia in inpatients. Other outcomes of interest to hospitalists (duration of intravenous therapy and length of stay) were not addressed. None of the studies compared a drug without atypical coverage (e.g., ceftriaxone) with the same drug plus another with atypical coverage (e.g., ceftriaxone plus azithromycin).

While guidelines still call for atypical coverage, the results of this review may provide support for hospitalists when treating patients with multiple drug allergies or intolerances who cannot be provided atypical coverage without significant side effects.

In-Home Hospital Care for Seniors

By Valerie J. Lang, MD

Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005:143(11):798-808.

Hospitalists are acutely aware of the hazards of hospitalization for older patients, and several models of providing hospital-level care in patients’ homes have been explored in other countries. This study evaluated a hospital-at-home program which provided acute, hospital-level care to patients ≥65-year-old in three U.S. cities. All patients required hospitalization and had one of the following diagnoses: community acquired pneumonia, CHF exacerbation, COPD exacerbation, or cellulitis. Most of the patients were admitted directly from the emergency department and were never admitted to the hospital.

The hospital-at-home program provided the following services: 1) at least eight-24 hours of continuous, one-on-one nursing; 2) intermittent nursing visits at least daily after continuous nursing was no longer required; 3) at least daily home visits and 24-hour availability by a hospital-at-home physician; 4) durable medical equipment; 5) skilled therapies and pharmacy support; 6) home radiology and ECG; and 7) intravenous fluids, antibiotics, other medications, oxygen, and other respiratory therapies. Patients were referred back to their primary care physicians after discharge from the hospital-at-home stay.

The study consisted of an observation phase followed by an intervention phase for comparison. The results show that the process of providing hospital-level care at home was feasible. Nurses arrived at patients’ homes within a mean of 20 minutes and provided a mean of 16.9 hours (range 0-71 hours) of continuous care, with a mean of 1.4 visits per day (range 0-5.3) after that. Physicians evaluated patients in the homes within a mean of 1.8 hours (range 0-4.5 hours) and provided a mean of 1.5 visits per day (range 0-5.3). There was variability among the sites for some measures. For example, oxygen was delivered to the home within an average of 0.6 or 0.7 hours at two sites, but within an average of 3.3 hours at the third site.

The intervention group had significantly less incident delirium (OR 0.26 [95% CI, 0.12-0.57]), less sedative medication use (OR 0.49 [95%CI, 0.30-0.81]), less use of chemical restraints (2% versus 7%; p=0.014), fewer critical complications (0% versus 6%; p≤0.001), and fewer deaths (0% versus 3%; p=0.050). Mean length of stay in the intervention group was 3.2 days vs. 4.9 days in the observation group (p=0.004). Mean costs were lower in the hospital-at-home group than the hospitalized group ($5,081 versus $7,480; p≤0.001).

 

There were important limitations to the study. Follow-up data was missing on a substantial number of patients (37% of observation group and 28% of intervention group). The 85 patients who were eligible but did not receive hospital-at-home care (either because they declined or the program wasn’t open for admissions from 10 p.m. to 6 a.m.) were combined with the 84 patients who did receive it under intention-to-treat, so the effects of the intervention may be underestimated.

Despite the limitations of the data, the findings of less delirium, sedative use, and chemical restraint use in the hospital-at-home group ring true, as patients were not subjected to the 24-hour noise, 4 a.m. blood draws, and unfamiliar surroundings that promote delirium, insomnia, and agitation in the hospital. Because delirium is common, difficult to prevent, and associated with longer lengths of stay, increased complications, and lower levels of functioning on discharge, the hospital-at-home model is worth studying further. If further evidence can be obtained to support this model, it may be worth pursuing in communities where there are adequate home care resources. Additionally, it may provide a new niche for hospitalists: the “Home Hospitalist.” TH

Benefits of Cardiac Resynchronization

By A. Rudmann, MD

Cleland J, Daubert J, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

A quarter to a third of patients with CHF have left or right bundle branch block, in which one side of the heart depolarizes and contracts before the other. Such electro-mechanical dyssynchrony is associated with decreased ejection fraction (EF), decreased cardiac output, and worse symptoms. A new pacemaker technology—called cardiac resynchronization therapy (CRT)—is a technically difficult procedure that involves placing a lead through the coronary sinus to the left side of the heart, re-establishing electro-mechanical synchrony. CRT improves EF and CHF symptoms, but its effect on mortality has been unknown.

In this unblinded trial funded and aided by Medtronic (a CRT device manufacturer) patients with class III-IV CHF despite standard medical therapy, ejection fraction <35%, and QRS >120 msec were randomized to CRT plus medical therapy or medical therapy alone. Patients with a major cardiovascular event in the preceding six weeks, conventional indication for pacemaker or defibrillator, continuous intravenous therapy for CHF, or atrial arrhythmia were excluded.

Eight-hundred-thirteen patients were followed for a mean of 2.5 years. The primary endpoint (a composite of death from any cause and first unplanned hospitalization for a major cardiovascular event) was reached by 39% of patients in the CRT arm versus 55% in the control arm. Death was also lower in the CRT group (20% versus 30%). Both outcomes were highly statistically significant. Other benefits of CRT included reduced hospitalization for worsening CHF (18% versus 33%), less severe symptoms, better quality of life, and higher left ventricular ejection fraction. Twelve percent of patients required more than one attempt to successfully insert the CRT device.

This study reports significant benefits for CRT added to medical therapy in patients with moderate-to-severe CHF, low EF, and cardiac dyssynchrony. The results are consistent with reported hemodynamic benefits of CRT. Limitations of the study include the unblinded methodology and close participation of the study sponsor in conducting the trial. Both raise questions about potential bias. Until other studies are available, clinicians should decide whether CRT is appropriate for individual patients. The cost effectiveness of CRT is not known.

Handoffs Finally Get Attention

By A. Rudmann, MD

Solet D, Norvell J, Rutan G, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099.

Handoffs involve the transfer of patient care responsibility from one clinician to another. In non-medical industries, analogous situations are known to be error-prone and have received substantial attention. However, despite the six-year-old Institute of Medicine study implicating poor communication as a major contributor to preventable deaths in U.S. hospitals, surprisingly little attention has been paid to handoffs by the medical community. A notable exception is AHRQ’s (the Agency for Healthcare Research and Quality) Web Morbidity and Mortality Rounds, which has highlighted the significance of poor communication among clinicians.

This article evaluates current handoff practices of the Indiana University School of Medicine (Indianapolis) internal medicine residency program. Major findings include significant variability in preparation, content, and method of handoffs across their four-hospital system. Barriers to effective handoff communication include lack of privacy, social hierarchy, language issues, lack of direct communication, inefficiency, and lack of formal education.

The authors propose Essential Elements for Successful Handoffs, including the following content items: complete team information, complete patient identification, brief history of present illness, active problems and past medical history, active medications, allergies, venous access status and contingencies, code status, pertinent lab data, concerns for the next 18-24 hours, long-term plans, and psychosocial concerns. Regarding process, the authors recommend both verbal and written communication routinely and bedside handoffs for high-risk patients. Additionally, they advise a formal handoff curriculum for residents, including both didactic instruction and attending role modeling.

 

While this may seem a tall order, the new 2006 National Patient Safety Goals now address handoff quality. As of January 1, JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requires all accredited institutions to perform handoffs that are both interactive (at least offering the opportunity to interact) and appropriately informative with up-to-date clinical information about diagnoses and treatments, stability, and recent or anticipated changes. All clinicians should evaluate the quality of handoffs in their own practices and make improvements as necessary. This article offers good suggestions on where to start.

The Use of Systemic Steroids for COPD

By A. Rudmann, MD

Niewoehner D, Erbland M, Deupree R, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340:1941-1947.

Systemic steroids are commonly prescribed for COPD exacerbation, despite adverse side effects including hyperglycemia, infections and osteoporosis. This randomized, double-blind, controlled trial conducted by the U.S. Department of Veterans Affairs (VA) compared two- and eight-week steroid regimens to placebo in patients also receiving broad spectrum antibiotics for seven days, inhaled beta-agonists, inhaled ipratropium bromide, and inhaled Triamcinolone Acetonide starting day four.

The steroid arms received methylprednisolone 125 mg every six hours for three days, then oral prednisone was tapered gradually from 60 mg over two or eight weeks. Inclusion criteria were clinical diagnosis of COPD exacerbation, age >50 years, >30 pack years of smoking, and either an FEV1 <1.5 or inability to undergo spirometry because of severe dyspnea. Patients with asthma, systemic steroid use in the preceding 30 days, and prognosis of less than one year were excluded.

In all, 1,870 patients were screened to enroll 271 patients who were followed for 182 days. Fifty percent of screened patients were ineligible due to recent steroid use. Systemic steroid treatment significantly reduced treatment failure at 30 days (23% versus 33%) and 90 days (37% versus 48%), but not at 182 days (51% versus 54%). Treatment failure was defined as death from any cause, mechanical ventilation, readmission for COPD, or intensification of pharmacologic therapy—which accounted for 70% of treatment failures at 30 days, 62% at 90 days, and 58% at 182 days. Seventy-five percent of the time this involved initiation of open-label systemic steroids. Two- and eight-week steroid regimens were equally efficacious. Steroid therapy reduced LOS from 9.7 to 8.5 days and improved FEV1 by a maximum of 0.1 L after one day. Mortality was not affected. Hyperglycemia was more common in the steroid groups (15% vs. 4%). Subgroup analysis showed that patients previously hospitalized benefited most from steroid therapy.

This study helps define the benefits and risks of systemic steroid therapy in COPD exacerbation. It reduces treatment failure rates at one and three months and reduces LOS, but increases hyperglycemia in patients receiving inhaled corticosteroids and other COPD treatments. About half of patients in the placebo arm required intensification of treatment, usually initiation of systemic steroid therapy; the other half averted systemic steroid therapy over six months of follow-up. Overall, this study suggests a rationale for deferring or limiting systemic steroid therapy in those patients without prior hospitalization for COPD and those at high risk for hyperglycemia.

Antibiotics for Atypical Coverage in Pneumonia Patients

By Valerie J. Lang, MD

Shefet D, Robenshtok E, Paul M, et al. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med. 2005:165:1992-2000.

Most guidelines recommend that inpatients with community-acquired pneumonia receive antibiotics that cover atypical organisms, though it is rare that an atypical organism causes pneumonia severe enough to require hospitalization. This review of 24 trials compared antibiotic regimens with and without atypical coverage in a total of 5,015 inpatients with community-acquired pneumonia. Atypical coverage was provided by quinolones or macrolides, and arms without atypical coverage included a wide variety of beta-lactam regimens. There was no difference in overall 30-day mortality with or without atypical coverage (RR 1.13 [95% CI, 0.82-1.54]).

 

For the outcome of clinical failure, there was a trend toward advantage in the quinolone monotherapy arms (RR, 0.89[95% CI, 0.77-1.02]), with a disadvantage in the macrolide monotherapy arms (RR, 1.17 [95% CI, 0.77-1.77]). However, when the studies with unclear or inadequate allocation concealment or allocation generation were excluded, the trend virtually resolved (RR, 0.99 [95%CI, 0.82-1.19]).

For the patients with documented atypical pathogens, there was a trend in favor of atypical coverage (RR, 0.52 [95% CI, 0.24-1.10]). This was significant for the subset of 43 patients with documented Legionella species, (RR, 0.17 [95% CI, 0.05-0.63]). Notably, there was no significant difference in results for different age groups overall.

Although these results support the authors’ conclusion that using antibiotics with or without atypical coverage achieve similar outcomes (except in the rare cases of Legionella species infections), most of the studies used treatment arms that are not in line with current guidelines for the treatment of community-acquired pneumonia in inpatients. Other outcomes of interest to hospitalists (duration of intravenous therapy and length of stay) were not addressed. None of the studies compared a drug without atypical coverage (e.g., ceftriaxone) with the same drug plus another with atypical coverage (e.g., ceftriaxone plus azithromycin).

While guidelines still call for atypical coverage, the results of this review may provide support for hospitalists when treating patients with multiple drug allergies or intolerances who cannot be provided atypical coverage without significant side effects.

In-Home Hospital Care for Seniors

By Valerie J. Lang, MD

Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005:143(11):798-808.

Hospitalists are acutely aware of the hazards of hospitalization for older patients, and several models of providing hospital-level care in patients’ homes have been explored in other countries. This study evaluated a hospital-at-home program which provided acute, hospital-level care to patients ≥65-year-old in three U.S. cities. All patients required hospitalization and had one of the following diagnoses: community acquired pneumonia, CHF exacerbation, COPD exacerbation, or cellulitis. Most of the patients were admitted directly from the emergency department and were never admitted to the hospital.

The hospital-at-home program provided the following services: 1) at least eight-24 hours of continuous, one-on-one nursing; 2) intermittent nursing visits at least daily after continuous nursing was no longer required; 3) at least daily home visits and 24-hour availability by a hospital-at-home physician; 4) durable medical equipment; 5) skilled therapies and pharmacy support; 6) home radiology and ECG; and 7) intravenous fluids, antibiotics, other medications, oxygen, and other respiratory therapies. Patients were referred back to their primary care physicians after discharge from the hospital-at-home stay.

The study consisted of an observation phase followed by an intervention phase for comparison. The results show that the process of providing hospital-level care at home was feasible. Nurses arrived at patients’ homes within a mean of 20 minutes and provided a mean of 16.9 hours (range 0-71 hours) of continuous care, with a mean of 1.4 visits per day (range 0-5.3) after that. Physicians evaluated patients in the homes within a mean of 1.8 hours (range 0-4.5 hours) and provided a mean of 1.5 visits per day (range 0-5.3). There was variability among the sites for some measures. For example, oxygen was delivered to the home within an average of 0.6 or 0.7 hours at two sites, but within an average of 3.3 hours at the third site.

The intervention group had significantly less incident delirium (OR 0.26 [95% CI, 0.12-0.57]), less sedative medication use (OR 0.49 [95%CI, 0.30-0.81]), less use of chemical restraints (2% versus 7%; p=0.014), fewer critical complications (0% versus 6%; p≤0.001), and fewer deaths (0% versus 3%; p=0.050). Mean length of stay in the intervention group was 3.2 days vs. 4.9 days in the observation group (p=0.004). Mean costs were lower in the hospital-at-home group than the hospitalized group ($5,081 versus $7,480; p≤0.001).

 

There were important limitations to the study. Follow-up data was missing on a substantial number of patients (37% of observation group and 28% of intervention group). The 85 patients who were eligible but did not receive hospital-at-home care (either because they declined or the program wasn’t open for admissions from 10 p.m. to 6 a.m.) were combined with the 84 patients who did receive it under intention-to-treat, so the effects of the intervention may be underestimated.

Despite the limitations of the data, the findings of less delirium, sedative use, and chemical restraint use in the hospital-at-home group ring true, as patients were not subjected to the 24-hour noise, 4 a.m. blood draws, and unfamiliar surroundings that promote delirium, insomnia, and agitation in the hospital. Because delirium is common, difficult to prevent, and associated with longer lengths of stay, increased complications, and lower levels of functioning on discharge, the hospital-at-home model is worth studying further. If further evidence can be obtained to support this model, it may be worth pursuing in communities where there are adequate home care resources. Additionally, it may provide a new niche for hospitalists: the “Home Hospitalist.” TH