Patient Care

Clinical question: How can the model for end-stage liver disease (MELD)-based model be updated and utilized to predict inpatient mortality rates of hospitalized cirrhotic patients with acute variceal bleeding (AVB)?

Background: AVB in cirrhosis continues to carry mortality rates as high as 20%. Risk prediction for individual patients is important to determine when a step-up in acuity of care is needed and to identify patients who would most benefit from preemptive treatments such as a transjugular intrahepatic portosystemic shunt. Many predictive models are available but are currently difficult to apply in the clinical setting.

Study design: Initial comparison data was collected via a prospective study from clinical records. Confirmation of updated MELD model occurred via cohort validation studies.

Setting: Prospective data collected from Hospital Clinic in Barcelona, Spain. Validation cohorts for new MELD model calibration completed in hospital settings in Canada and Spain.

Synopsis: Data was collected from 178 patients with cirrhosis and esophageal AVB receiving standard therapy from 2007-2010. Esophageal bleeding was confirmed endoscopically. The primary endpoint was six-week, bleeding-related mortality. Among all the subjects studied, the average six-week mortality rate was 16%. Models evaluated for validity included the Child-Pugh, the D’Amico and Augustin models, and the MELD score.

Each model was assessed via discrimination, calibration, and overall performance in mortality prediction. The MELD was identified as the best model in terms of discrimination and overall performance but was miscalibrated. The original validation cohort from the Hospital Clinic in Spain was utilized to update the MELD calibration via logistic regression. External validation was completed via cohort studies in Canada (N=240) and at Vall D’Hebron Hospital in Spain (N=221).

Using the updated model, the MELD score adds a predictive component in the setting of AVB that has not been available. MELD values of 19 and higher predict mortality >20%, whereas MELD values lower than 11 predict mortality of 5%.

Bottom line: Utilization of the updated MELD model may provide a more accurate method to identify patients in which more aggressive preemptive therapies are indicated using prognostic predictions of mortality.

Citation: Reverter E, Tandon P, Augustin S, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146(2):412-419.

Clinical question: How can the model for end-stage liver disease (MELD)-based model be updated and utilized to predict inpatient mortality rates of hospitalized cirrhotic patients with acute variceal bleeding (AVB)?

Background: AVB in cirrhosis continues to carry mortality rates as high as 20%. Risk prediction for individual patients is important to determine when a step-up in acuity of care is needed and to identify patients who would most benefit from preemptive treatments such as a transjugular intrahepatic portosystemic shunt. Many predictive models are available but are currently difficult to apply in the clinical setting.

Study design: Initial comparison data was collected via a prospective study from clinical records. Confirmation of updated MELD model occurred via cohort validation studies.

Setting: Prospective data collected from Hospital Clinic in Barcelona, Spain. Validation cohorts for new MELD model calibration completed in hospital settings in Canada and Spain.

Synopsis: Data was collected from 178 patients with cirrhosis and esophageal AVB receiving standard therapy from 2007-2010. Esophageal bleeding was confirmed endoscopically. The primary endpoint was six-week, bleeding-related mortality. Among all the subjects studied, the average six-week mortality rate was 16%. Models evaluated for validity included the Child-Pugh, the D’Amico and Augustin models, and the MELD score.

Each model was assessed via discrimination, calibration, and overall performance in mortality prediction. The MELD was identified as the best model in terms of discrimination and overall performance but was miscalibrated. The original validation cohort from the Hospital Clinic in Spain was utilized to update the MELD calibration via logistic regression. External validation was completed via cohort studies in Canada (N=240) and at Vall D’Hebron Hospital in Spain (N=221).

Using the updated model, the MELD score adds a predictive component in the setting of AVB that has not been available. MELD values of 19 and higher predict mortality >20%, whereas MELD values lower than 11 predict mortality of 5%.

Bottom line: Utilization of the updated MELD model may provide a more accurate method to identify patients in which more aggressive preemptive therapies are indicated using prognostic predictions of mortality.

Citation: Reverter E, Tandon P, Augustin S, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146(2):412-419.

Clinical question: How can the model for end-stage liver disease (MELD)-based model be updated and utilized to predict inpatient mortality rates of hospitalized cirrhotic patients with acute variceal bleeding (AVB)?

Background: AVB in cirrhosis continues to carry mortality rates as high as 20%. Risk prediction for individual patients is important to determine when a step-up in acuity of care is needed and to identify patients who would most benefit from preemptive treatments such as a transjugular intrahepatic portosystemic shunt. Many predictive models are available but are currently difficult to apply in the clinical setting.

Study design: Initial comparison data was collected via a prospective study from clinical records. Confirmation of updated MELD model occurred via cohort validation studies.

Setting: Prospective data collected from Hospital Clinic in Barcelona, Spain. Validation cohorts for new MELD model calibration completed in hospital settings in Canada and Spain.

Synopsis: Data was collected from 178 patients with cirrhosis and esophageal AVB receiving standard therapy from 2007-2010. Esophageal bleeding was confirmed endoscopically. The primary endpoint was six-week, bleeding-related mortality. Among all the subjects studied, the average six-week mortality rate was 16%. Models evaluated for validity included the Child-Pugh, the D’Amico and Augustin models, and the MELD score.

Each model was assessed via discrimination, calibration, and overall performance in mortality prediction. The MELD was identified as the best model in terms of discrimination and overall performance but was miscalibrated. The original validation cohort from the Hospital Clinic in Spain was utilized to update the MELD calibration via logistic regression. External validation was completed via cohort studies in Canada (N=240) and at Vall D’Hebron Hospital in Spain (N=221).

Using the updated model, the MELD score adds a predictive component in the setting of AVB that has not been available. MELD values of 19 and higher predict mortality >20%, whereas MELD values lower than 11 predict mortality of 5%.

Bottom line: Utilization of the updated MELD model may provide a more accurate method to identify patients in which more aggressive preemptive therapies are indicated using prognostic predictions of mortality.

Citation: Reverter E, Tandon P, Augustin S, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146(2):412-419.

Clinical question: What is the national burden of ED visits and hospitalizations for insulin-related hypoglycemia?

Background: As the prevalence of diabetes mellitus continues to rise, the use of insulin and the burden of insulin-related hypoglycemia on our healthcare system will increase. By identifying high-risk populations and analyzing the circumstances of insulin-related hypoglycemia, we might be able to identify and employ strategies to decrease the risk of insulin use.

Study design: Observational study using national adverse drug surveillance database and national household survey.

Setting: U.S. hospitals, excluding psychiatric and penal institutions.

Synopsis: Using data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance (NEISS-CADES) Project and the National Health Interview Survey (NHIS), the authors estimated the rates and characteristics of ED visits and hospitalizations for insulin-related hypoglycemia. The authors estimated that about 100,000 ED visits occur nationally and that almost one-third of those visits result in hospitalization. Compared to younger patients treated with insulin, patients 80 years or older were more likely to present to the ED (rate ratio, 2.5; 95% CI, 1.5-4.3) and much more likely to be subsequently hospitalized (rate ratio, 4.9; 95% CI, 2.6-9.1) for insulin-related hypoglycemia.

The most common causes of insulin-induced hypoglycemia were failure to reduce insulin during periods of reduced food intake and confusion between short-acting and long-acting insulin. The authors suggest that looser glycemic control be sought in elderly patients to decrease the risk of insulin-related hypoglycemia and subsequent sequelae. Patient education addressing common insulin errors might also decrease the burden of ED visits and hospitalizations related to insulin.

Bottom line: Risks of hypoglycemia in patients older than 80 should be considered prior to starting an insulin regimen or prior to increasing the dose of insulin.

Citation: Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174(5):678-686.

Clinical question: What is the national burden of ED visits and hospitalizations for insulin-related hypoglycemia?

Background: As the prevalence of diabetes mellitus continues to rise, the use of insulin and the burden of insulin-related hypoglycemia on our healthcare system will increase. By identifying high-risk populations and analyzing the circumstances of insulin-related hypoglycemia, we might be able to identify and employ strategies to decrease the risk of insulin use.

Study design: Observational study using national adverse drug surveillance database and national household survey.

Setting: U.S. hospitals, excluding psychiatric and penal institutions.

Synopsis: Using data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance (NEISS-CADES) Project and the National Health Interview Survey (NHIS), the authors estimated the rates and characteristics of ED visits and hospitalizations for insulin-related hypoglycemia. The authors estimated that about 100,000 ED visits occur nationally and that almost one-third of those visits result in hospitalization. Compared to younger patients treated with insulin, patients 80 years or older were more likely to present to the ED (rate ratio, 2.5; 95% CI, 1.5-4.3) and much more likely to be subsequently hospitalized (rate ratio, 4.9; 95% CI, 2.6-9.1) for insulin-related hypoglycemia.

The most common causes of insulin-induced hypoglycemia were failure to reduce insulin during periods of reduced food intake and confusion between short-acting and long-acting insulin. The authors suggest that looser glycemic control be sought in elderly patients to decrease the risk of insulin-related hypoglycemia and subsequent sequelae. Patient education addressing common insulin errors might also decrease the burden of ED visits and hospitalizations related to insulin.

Bottom line: Risks of hypoglycemia in patients older than 80 should be considered prior to starting an insulin regimen or prior to increasing the dose of insulin.

Citation: Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174(5):678-686.

Clinical question: What is the national burden of ED visits and hospitalizations for insulin-related hypoglycemia?

Background: As the prevalence of diabetes mellitus continues to rise, the use of insulin and the burden of insulin-related hypoglycemia on our healthcare system will increase. By identifying high-risk populations and analyzing the circumstances of insulin-related hypoglycemia, we might be able to identify and employ strategies to decrease the risk of insulin use.

Study design: Observational study using national adverse drug surveillance database and national household survey.

Setting: U.S. hospitals, excluding psychiatric and penal institutions.

Synopsis: Using data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance (NEISS-CADES) Project and the National Health Interview Survey (NHIS), the authors estimated the rates and characteristics of ED visits and hospitalizations for insulin-related hypoglycemia. The authors estimated that about 100,000 ED visits occur nationally and that almost one-third of those visits result in hospitalization. Compared to younger patients treated with insulin, patients 80 years or older were more likely to present to the ED (rate ratio, 2.5; 95% CI, 1.5-4.3) and much more likely to be subsequently hospitalized (rate ratio, 4.9; 95% CI, 2.6-9.1) for insulin-related hypoglycemia.

The most common causes of insulin-induced hypoglycemia were failure to reduce insulin during periods of reduced food intake and confusion between short-acting and long-acting insulin. The authors suggest that looser glycemic control be sought in elderly patients to decrease the risk of insulin-related hypoglycemia and subsequent sequelae. Patient education addressing common insulin errors might also decrease the burden of ED visits and hospitalizations related to insulin.

Bottom line: Risks of hypoglycemia in patients older than 80 should be considered prior to starting an insulin regimen or prior to increasing the dose of insulin.

Citation: Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174(5):678-686.

Clinical question: What are the perceptions of patients and healthcare personnel (HCP) regarding attire, and what evidence exists for contamination and transmission of pathogenic microorganisms by HCP attire?

Background: HCP attire is an important aspect of the healthcare profession. There is increasing concern for microorganism transmission in the hospital by fomites, including HCP apparel, and studies demonstrate contamination of HCP apparel; however, there is a lack of evidence demonstrating the role of HCP apparel in transmission of microorganisms to patients.

Study design: Literature and policy review, survey of Society for Healthcare Epidemiology of America (SHEA) members.

Setting: Literature search from January 2013 to March 2013 for articles related to bacterial contamination and laundering of HCP attire and patient and provider perceptions of HCP attire and/or footwear. Review of policies related to HCP attire from seven large teaching hospitals.

Synopsis: The search identified 26 articles that studied patients’ perceptions of HCP attire and only four studies that reviewed HCP preferences relating to attire. There were 11 small prospective studies related to pathogen contamination of HCP apparel but no clinical studies demonstrating transmission of pathogens from HCP attire to patients. There was one report of a pathogen outbreak potentially related to HCP apparel.

Hospital policies primarily related to general appearance and dress for all employees without significant specifications for HCP outside of sterile or procedure-based areas. One institution recommended bare below the elbows (BBE) attire for physicians during patient care activities.

There were 337 responses (21.7% response rate) to the survey, which showed poor enforcement of HCP attire policies, but a majority of respondents felt that the role of HCP attire in the transmission of pathogens in the healthcare setting was very important or somewhat important.

Patients preferred formal attire, including a white coat, but this preference had limited impact on patient satisfaction or confidence in practitioners. Patients did not perceive HCP attire as an infection risk but were willing to change their preference for formal attire when informed of this potential risk.

BBE policies are in effect at some U.S. hospitals and in the United Kingdom, but the effect on healthcare-associated infection rates and transmission of pathogens to patients is unknown.

Bottom line: Contamination of HCP attire with healthcare pathogens occurs, but no clinical data currently exists related to transmission of these pathogens to patients and its impact on the healthcare system. Patient satisfaction and confidence are not affected by less formal attire when informed of potential infection risks.

Citation: Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol. 2014;35(2):107-121.

Clinical question: What are the perceptions of patients and healthcare personnel (HCP) regarding attire, and what evidence exists for contamination and transmission of pathogenic microorganisms by HCP attire?

Background: HCP attire is an important aspect of the healthcare profession. There is increasing concern for microorganism transmission in the hospital by fomites, including HCP apparel, and studies demonstrate contamination of HCP apparel; however, there is a lack of evidence demonstrating the role of HCP apparel in transmission of microorganisms to patients.

Study design: Literature and policy review, survey of Society for Healthcare Epidemiology of America (SHEA) members.

Setting: Literature search from January 2013 to March 2013 for articles related to bacterial contamination and laundering of HCP attire and patient and provider perceptions of HCP attire and/or footwear. Review of policies related to HCP attire from seven large teaching hospitals.

Synopsis: The search identified 26 articles that studied patients’ perceptions of HCP attire and only four studies that reviewed HCP preferences relating to attire. There were 11 small prospective studies related to pathogen contamination of HCP apparel but no clinical studies demonstrating transmission of pathogens from HCP attire to patients. There was one report of a pathogen outbreak potentially related to HCP apparel.

Hospital policies primarily related to general appearance and dress for all employees without significant specifications for HCP outside of sterile or procedure-based areas. One institution recommended bare below the elbows (BBE) attire for physicians during patient care activities.

There were 337 responses (21.7% response rate) to the survey, which showed poor enforcement of HCP attire policies, but a majority of respondents felt that the role of HCP attire in the transmission of pathogens in the healthcare setting was very important or somewhat important.

Patients preferred formal attire, including a white coat, but this preference had limited impact on patient satisfaction or confidence in practitioners. Patients did not perceive HCP attire as an infection risk but were willing to change their preference for formal attire when informed of this potential risk.

BBE policies are in effect at some U.S. hospitals and in the United Kingdom, but the effect on healthcare-associated infection rates and transmission of pathogens to patients is unknown.

Bottom line: Contamination of HCP attire with healthcare pathogens occurs, but no clinical data currently exists related to transmission of these pathogens to patients and its impact on the healthcare system. Patient satisfaction and confidence are not affected by less formal attire when informed of potential infection risks.

Citation: Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol. 2014;35(2):107-121.

Clinical question: What are the perceptions of patients and healthcare personnel (HCP) regarding attire, and what evidence exists for contamination and transmission of pathogenic microorganisms by HCP attire?

Background: HCP attire is an important aspect of the healthcare profession. There is increasing concern for microorganism transmission in the hospital by fomites, including HCP apparel, and studies demonstrate contamination of HCP apparel; however, there is a lack of evidence demonstrating the role of HCP apparel in transmission of microorganisms to patients.

Study design: Literature and policy review, survey of Society for Healthcare Epidemiology of America (SHEA) members.

Setting: Literature search from January 2013 to March 2013 for articles related to bacterial contamination and laundering of HCP attire and patient and provider perceptions of HCP attire and/or footwear. Review of policies related to HCP attire from seven large teaching hospitals.

Synopsis: The search identified 26 articles that studied patients’ perceptions of HCP attire and only four studies that reviewed HCP preferences relating to attire. There were 11 small prospective studies related to pathogen contamination of HCP apparel but no clinical studies demonstrating transmission of pathogens from HCP attire to patients. There was one report of a pathogen outbreak potentially related to HCP apparel.

Hospital policies primarily related to general appearance and dress for all employees without significant specifications for HCP outside of sterile or procedure-based areas. One institution recommended bare below the elbows (BBE) attire for physicians during patient care activities.

There were 337 responses (21.7% response rate) to the survey, which showed poor enforcement of HCP attire policies, but a majority of respondents felt that the role of HCP attire in the transmission of pathogens in the healthcare setting was very important or somewhat important.

Patients preferred formal attire, including a white coat, but this preference had limited impact on patient satisfaction or confidence in practitioners. Patients did not perceive HCP attire as an infection risk but were willing to change their preference for formal attire when informed of this potential risk.

BBE policies are in effect at some U.S. hospitals and in the United Kingdom, but the effect on healthcare-associated infection rates and transmission of pathogens to patients is unknown.

Bottom line: Contamination of HCP attire with healthcare pathogens occurs, but no clinical data currently exists related to transmission of these pathogens to patients and its impact on the healthcare system. Patient satisfaction and confidence are not affected by less formal attire when informed of potential infection risks.

Citation: Bearman G, Bryant K, Leekha S, et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol. 2014;35(2):107-121.

Clinical question: What are the risk factors associated with potentially avoidable readmissions (PARs) for end-of-life care issues?

Background: The 6% of Medicare beneficiaries who die each year account for 30% of yearly Medicare expenditures on medical treatments, with repeated hospitalizations a frequent occurrence at the end of life. There are many opportunities to improve the care of patients at the end of life.

Study design: Nested case-control.

Setting: Academic, tertiary-care medical center.

Synopsis: There were 10,275 eligible admissions to Brigham and Women’s Hospital in Boston from July 1, 2009 to June 30, 2010, with a length of stay less than one day. There were 2,301 readmissions within 30 days of the index hospitalization, of which 826 were considered potentially avoidable. From a random sample of 594 of these patients, 80 patients had PAR related to end-of-life care issues. There were 7,974 patients who were not admitted within 30 days of index admission (controls). The primary study outcome was any 30-day PAR due to end-of-life care issues. A readmission was considered a PAR if it related to previously known conditions from the index hospitalization or was due to a complication of treatment.

The four factors that were significantly associated with 30-day PAR for end-of-life care issues were: neoplasm (OR 5.6, 95% CI: 2.85-11.0), opiate medication at discharge (OR 2.29, 95% CI: 1.29-4.07), Elixhauser comorbidity index, per five-unit increase (OR 1.16, 95% CI: 1.10-1.22), and number of admissions in previous 12 months (OR 1.10, 95% CI: 1.02-1.20). The model that included all four variables had excellent discrimination power, with a C-statistic of 0.85.

Bottom line: The factors from this prediction model can be used, formally or informally, to identify those patients at higher risk for readmission for end-of-life care issues and prioritize resources to help minimize this risk.

Citation: Donzé J, Lipsitz S, Schnipper JL. Risk factors for potentially avoidable readmissions due to end-of-life care issues. J Hosp Med. 2014;9(5):310-314.

Clinical question: What are the risk factors associated with potentially avoidable readmissions (PARs) for end-of-life care issues?

Background: The 6% of Medicare beneficiaries who die each year account for 30% of yearly Medicare expenditures on medical treatments, with repeated hospitalizations a frequent occurrence at the end of life. There are many opportunities to improve the care of patients at the end of life.

Study design: Nested case-control.

Setting: Academic, tertiary-care medical center.

Synopsis: There were 10,275 eligible admissions to Brigham and Women’s Hospital in Boston from July 1, 2009 to June 30, 2010, with a length of stay less than one day. There were 2,301 readmissions within 30 days of the index hospitalization, of which 826 were considered potentially avoidable. From a random sample of 594 of these patients, 80 patients had PAR related to end-of-life care issues. There were 7,974 patients who were not admitted within 30 days of index admission (controls). The primary study outcome was any 30-day PAR due to end-of-life care issues. A readmission was considered a PAR if it related to previously known conditions from the index hospitalization or was due to a complication of treatment.

The four factors that were significantly associated with 30-day PAR for end-of-life care issues were: neoplasm (OR 5.6, 95% CI: 2.85-11.0), opiate medication at discharge (OR 2.29, 95% CI: 1.29-4.07), Elixhauser comorbidity index, per five-unit increase (OR 1.16, 95% CI: 1.10-1.22), and number of admissions in previous 12 months (OR 1.10, 95% CI: 1.02-1.20). The model that included all four variables had excellent discrimination power, with a C-statistic of 0.85.

Bottom line: The factors from this prediction model can be used, formally or informally, to identify those patients at higher risk for readmission for end-of-life care issues and prioritize resources to help minimize this risk.

Citation: Donzé J, Lipsitz S, Schnipper JL. Risk factors for potentially avoidable readmissions due to end-of-life care issues. J Hosp Med. 2014;9(5):310-314.

Clinical question: What are the risk factors associated with potentially avoidable readmissions (PARs) for end-of-life care issues?

Background: The 6% of Medicare beneficiaries who die each year account for 30% of yearly Medicare expenditures on medical treatments, with repeated hospitalizations a frequent occurrence at the end of life. There are many opportunities to improve the care of patients at the end of life.

Study design: Nested case-control.

Setting: Academic, tertiary-care medical center.

Synopsis: There were 10,275 eligible admissions to Brigham and Women’s Hospital in Boston from July 1, 2009 to June 30, 2010, with a length of stay less than one day. There were 2,301 readmissions within 30 days of the index hospitalization, of which 826 were considered potentially avoidable. From a random sample of 594 of these patients, 80 patients had PAR related to end-of-life care issues. There were 7,974 patients who were not admitted within 30 days of index admission (controls). The primary study outcome was any 30-day PAR due to end-of-life care issues. A readmission was considered a PAR if it related to previously known conditions from the index hospitalization or was due to a complication of treatment.

The four factors that were significantly associated with 30-day PAR for end-of-life care issues were: neoplasm (OR 5.6, 95% CI: 2.85-11.0), opiate medication at discharge (OR 2.29, 95% CI: 1.29-4.07), Elixhauser comorbidity index, per five-unit increase (OR 1.16, 95% CI: 1.10-1.22), and number of admissions in previous 12 months (OR 1.10, 95% CI: 1.02-1.20). The model that included all four variables had excellent discrimination power, with a C-statistic of 0.85.

Bottom line: The factors from this prediction model can be used, formally or informally, to identify those patients at higher risk for readmission for end-of-life care issues and prioritize resources to help minimize this risk.

Citation: Donzé J, Lipsitz S, Schnipper JL. Risk factors for potentially avoidable readmissions due to end-of-life care issues. J Hosp Med. 2014;9(5):310-314.

Clinical question: What is the benefit of routine colonic evaluation after an episode of acute diverticulitis?

Background: Currently accepted guidelines recommend routine colonic evaluation (colonoscopy, computed tomography (CT) colonography) after an episode of acute diverticulitis to confirm the diagnosis and exclude malignancy. Increased use of CT to confirm the diagnosis of acute diverticulitis and exclude associated complications has brought into question the recommendation for routine colonic evaluation after an episode of acute diverticulitis.

Study design: Meta-analysis.

Setting: Search of online databases and the Cochrane Library.

Synopsis: Eleven studies from seven countries included 1,970 patients who had a colonic evaluation after an episode of acute diverticulitis. The risk of finding a malignancy was 1.6%. Within this population, 1,497 patients were identified as having uncomplicated diverticulitis. Cancer was found in only five patients (proportional risk estimate 0.7%).

For the 79 patients identified as having complicated diverticulitis, the risk of finding a malignancy on subsequent screening was 10.8%.

Every systematic review is limited by the quality of the studies available for review and the differences in design and methodology of the studies. In this meta-analysis, the risk of finding cancer after an episode of uncomplicated diverticulitis appears to be low. Given the limited resources of the healthcare system and the small but real risk of morbidity and mortality associated with invasive colonic procedures, the routine recommendation for colon cancer screening after an episode of acute uncomplicated diverticulitis should be further evaluated.

Bottom line: The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, additional routine colonic evaluation may not be necessary.

Citation: Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-272.

Clinical question: What is the benefit of routine colonic evaluation after an episode of acute diverticulitis?

Background: Currently accepted guidelines recommend routine colonic evaluation (colonoscopy, computed tomography (CT) colonography) after an episode of acute diverticulitis to confirm the diagnosis and exclude malignancy. Increased use of CT to confirm the diagnosis of acute diverticulitis and exclude associated complications has brought into question the recommendation for routine colonic evaluation after an episode of acute diverticulitis.

Study design: Meta-analysis.

Setting: Search of online databases and the Cochrane Library.

Synopsis: Eleven studies from seven countries included 1,970 patients who had a colonic evaluation after an episode of acute diverticulitis. The risk of finding a malignancy was 1.6%. Within this population, 1,497 patients were identified as having uncomplicated diverticulitis. Cancer was found in only five patients (proportional risk estimate 0.7%).

For the 79 patients identified as having complicated diverticulitis, the risk of finding a malignancy on subsequent screening was 10.8%.

Every systematic review is limited by the quality of the studies available for review and the differences in design and methodology of the studies. In this meta-analysis, the risk of finding cancer after an episode of uncomplicated diverticulitis appears to be low. Given the limited resources of the healthcare system and the small but real risk of morbidity and mortality associated with invasive colonic procedures, the routine recommendation for colon cancer screening after an episode of acute uncomplicated diverticulitis should be further evaluated.

Bottom line: The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, additional routine colonic evaluation may not be necessary.

Citation: Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-272.

Clinical question: What is the benefit of routine colonic evaluation after an episode of acute diverticulitis?

Background: Currently accepted guidelines recommend routine colonic evaluation (colonoscopy, computed tomography (CT) colonography) after an episode of acute diverticulitis to confirm the diagnosis and exclude malignancy. Increased use of CT to confirm the diagnosis of acute diverticulitis and exclude associated complications has brought into question the recommendation for routine colonic evaluation after an episode of acute diverticulitis.

Study design: Meta-analysis.

Setting: Search of online databases and the Cochrane Library.

Synopsis: Eleven studies from seven countries included 1,970 patients who had a colonic evaluation after an episode of acute diverticulitis. The risk of finding a malignancy was 1.6%. Within this population, 1,497 patients were identified as having uncomplicated diverticulitis. Cancer was found in only five patients (proportional risk estimate 0.7%).

For the 79 patients identified as having complicated diverticulitis, the risk of finding a malignancy on subsequent screening was 10.8%.

Every systematic review is limited by the quality of the studies available for review and the differences in design and methodology of the studies. In this meta-analysis, the risk of finding cancer after an episode of uncomplicated diverticulitis appears to be low. Given the limited resources of the healthcare system and the small but real risk of morbidity and mortality associated with invasive colonic procedures, the routine recommendation for colon cancer screening after an episode of acute uncomplicated diverticulitis should be further evaluated.

Bottom line: The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, additional routine colonic evaluation may not be necessary.

Citation: Sharma PV, Eglinton T, Hider P, Frizelle F. Systematic review and meta-analysis of the role of routine colonic evaluation after radiologically confirmed acute diverticulitis. Ann Surg. 2014;259(2):263-272.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?

Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.

Study design: Randomized controlled trial (RCT).

Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.

Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.

Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.

Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.

Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.

Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.

Nurse practitioners and physician assistants are a critical part of the hospitalist care team. Together with the American Academy of Physician Assistants, SHM is hosting the annual Adult Hospital Medicine Boot Camp (www.aapa.org/bootcamp) specifically for nurse practitioners (NPs) and physician assistants (PAs).

The four-day program helps PAs and NPs stay up to date on the most common diagnoses, diseases, and treatments for hospitalized patients (27.75 hours Category 1 CME). A pre-course for PAs and NPs new to hospital medicine introduces them to the unique demands of inpatient care (eight hours Category 1 CME).

Adult Hospital Medicine Boot Camp October 2-5, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Hospital Medicine 101

October 1, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Nurse practitioners and physician assistants are a critical part of the hospitalist care team. Together with the American Academy of Physician Assistants, SHM is hosting the annual Adult Hospital Medicine Boot Camp (www.aapa.org/bootcamp) specifically for nurse practitioners (NPs) and physician assistants (PAs).

The four-day program helps PAs and NPs stay up to date on the most common diagnoses, diseases, and treatments for hospitalized patients (27.75 hours Category 1 CME). A pre-course for PAs and NPs new to hospital medicine introduces them to the unique demands of inpatient care (eight hours Category 1 CME).

Adult Hospital Medicine Boot Camp October 2-5, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Hospital Medicine 101

October 1, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Nurse practitioners and physician assistants are a critical part of the hospitalist care team. Together with the American Academy of Physician Assistants, SHM is hosting the annual Adult Hospital Medicine Boot Camp (www.aapa.org/bootcamp) specifically for nurse practitioners (NPs) and physician assistants (PAs).

The four-day program helps PAs and NPs stay up to date on the most common diagnoses, diseases, and treatments for hospitalized patients (27.75 hours Category 1 CME). A pre-course for PAs and NPs new to hospital medicine introduces them to the unique demands of inpatient care (eight hours Category 1 CME).

Adult Hospital Medicine Boot Camp October 2-5, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

Hospital Medicine 101

October 1, 2014

The Westin Peachtree Plaza, Atlanta

www.aapa.org/bootcamp

"What’s the bigger picture here?” Hospitalist Christopher Moreland, MD, MPH, FACP, drops his question neatly into the pause in resident Adrienne Victor, MD’s presentation of patient status and lab results.

We’re on the bustling 9th floor of University Hospital at the University of Texas Health Science Center (UTHSCSA) in San Antonio during fast-paced morning rounds. As attending physician, Dr. Moreland is focusing intently on Dr. Victor’s face, simultaneously monitoring the American Sign Language (ASL) interpretation of Todd Agan, CI/CT, BEI Master Interpreter. Immediately after his question to Dr. Victor, the discussion—conducted in both ASL and spoken English—shifts to the patient’s psychosocial issues and whether a palliative care consult would be advisable.

It’s clear that for Dr. Moreland, the work, not his lack of hearing, is the main point here. A hospitalist with the UTHSCSA team since 2010, Dr. Moreland quickly established himself not only as a valuable HM team member and educator, but also as a leader in other domains. For example, in addition to his academic appointment as assistant clinical professor of medicine, he previously was co-director of the medicine consult and co-management service at University Hospital and now serves as UTHSCSA’s associate program director for the internal medicine residency program.

Dr. Moreland’s question this morning is typical of his teaching, says Bret Simon, PhD, an educational development specialist and assistant professor with the division of hospital medicine at UTHSCSA.

“I grew up working with interpreters, so I’m used to that process. “It forces you to become less inhibited about what you’re doing.”

–Christopher Moreland, MD, MPH, FACP

“He’s very good at using questions to teach, promoting reflection rather than simply telling the student what to do,” Dr. Simon explains.

Why Medicine?

Chris Moreland’s parents discovered their son was deaf at age two, by which time he had acquired very few spoken words. After multiple visits to healthcare professionals, a physician finally identified his deafness. The family then embarked on a bimodal approach to his education, using both signed and spoken English. He learned ASL in college. As a result, he communicates through a variety of channels: ASL with interpreters Agan and Keri Richardson, speech reading, and spoken English. When examining patients, he uses an electronic stethoscope that interfaces with his cochlear implant.

Medicine was not Dr. Moreland’s first academic choice.

“I went into college thinking I wanted to do computer science,” he says, speaking of his undergraduate studies at the University of Texas in Austin. When he realized computers were not for him, he switched his major to theater arts, continuing an interest he had had in high school. After that, research seemed appealing, and he became a research assistant in a lab in the Department of Anthropology. Finally, after shadowing a number of physicians, his interest in medical science was stimulated.

“Medicine,” he says, “became a nice culmination of everything I was interested in doing.” From computer science, he learned to appreciate an understanding of algorithms; from theater arts came the ability to understand where people are coming from; and from his link with research in linguistics and anthropology came the contribution of problem solving and methodology.

Fearless Communicator

Dr. Moreland says his deafness presents no impediments to his practice of medicine. “I grew up working with interpreters, so I’m used to that process,” he says. “It forces you to become less inhibited about what you’re doing. People have questions [‘who is that other person in the room?’], and you learn how to handle those questions quickly, without interfering with communication in order to advance the work.”

When Dr. Moreland started his clinical rotations as a third-year medical student, he grappled with the best way to introduce himself and his interpreter to patients. His first attempt at explaining the interpretive process “went on for quite a while” and was too much information. “It ended up overwhelming the patient,” he says.

The next time he chose not to introduce the interpreter but to simply address the patient directly. “That didn’t work either, because the patient’s eyes kept wandering to that other person in the room.”

Finally, “I realized that it wasn’t about me,” he says. “It was about the patient.” So he simply shortened the introduction to himself and the interpreter and asked the patients how they were doing.

“Once I became more professional about the situation, the more positive and patient-centered it became, and it went well.” He says he’s had no negative experiences since then, at least not related to his deafness. He approaches each new patient interaction proactively, and he and his interpreters become part of the flow of care.

Teaching’s Missing Pieces

As illustrated with his first question, Dr. Moreland intends for his trainees to learn to think globally about their patients.

“Although rote information has its role,” he explains later in the conference room, “I’m always afraid of overemphasizing it. When I trained in medical school, we didn’t learn that much about communication skills and teamwork. We talked a lot about information we use as physicians—the mechanism of disease, the drugs we use.

“What I try to emphasize with trainees is, what skills in communication, teamwork, and self-education can we develop so that we can use those skills continuously throughout our practice?”

Dr. Moreland takes setting resident-generated learning goals seriously, says Dr. Simon, for which he and trainees give him high marks.

“He is very supportive and encourages us to make our own management decisions,” Dr. Victor says. “Though, of course, he will let us know if something is likely the wrong choice, usually by discussing it first.”

Patrick S. Romano, MD, MPH, professor of general medicine and pediatrics and former director of the Primary Care Outcomes Research (PCOR) faculty development program at the University of California Davis, where Dr. Moreland was a resident and then a fellow, found his trainee was always “very thoughtful and conscientious, presenting different ways of looking at problems and asking the right questions. And, of course, that’s what we look for in teachers: people who know how to ask the right questions, because, then, of course, they are able to answer students’ questions.”

Transformational and Inspirational

For many of Dr. Moreland’s colleagues and trainees, working with him has been their first exposure to a hearing-impaired physician. Richard L. Kravitz, MD, MSPH, professor and co-vice chair of research in the department of medicine at UC Davis, supervised Dr. Moreland during his residency and later during his PCOR fellowship. The American Disabilities Act-mandated interpreter for Dr. Moreland introduced a “change in standard operating procedure,” Dr. Kravitz notes. “None of us knew what to expect when he came onboard the residency program. But, very quickly, any unease was put to rest because he was just so talented.”

For visitors, Dr. Moreland seamlessly addresses his hearing impairment and makes sure that everyone on the team is following the discussion. Luci K. Leykum, MD, MBA, MSc, hospital medicine division chief and associate dean for clinical affairs at UTHSCSA, says that Dr. Moreland has brought “a lot of positive energy to the group—and in ways I would not have expected.” She praised his talents as both a clinician and teacher.

John G. Rees, DBA, RN, patient care coordinator in the 5th Acute Care Unit, says that Dr. Moreland immediately “blended” with the staff on his service. “The rapport was perfect,” he adds.

Robert L. Talbert, PharmD, the SmithKline Centennial Professor of Pharmacy at the College of Pharmacy at the University of Texas at Austin, often participates in teaching rounds. Dr. Moreland, he says, “has an excellent fund of knowledge; he’s very rational and evidence-based in decisions he makes. He’s exactly what a physician should be.”

Watching interpreters Agan and Richardson during group meetings, Dr. Leykum believes, has influenced their group dynamics. “On a subtle level, having Chris in the group has made us more aware of how we interact with each other.”

Nilam Soni, MD, FHM associate professor in the department of medicine and leader of ultrasound education, has noticed that he has become attuned to Dr. Moreland’s way of communicating and often does not need the interpreters to decipher the conversation between them. Working with Dr. Moreland has given Dr. Soni “a better understanding of how to communicate effectively with patients that have difficulty hearing.”

After working with Dr. Moreland at UC Davis, Dr. Kravitz observed that employing physicians with hearing impairment or other disabilities brings additional benefits to the institution. Dr. Moreland’s presence “probably raised the level of understanding of the entire internal medicine staff, because it demonstrated that a disability is what you make of it,” he says. “One recognizes how porous the barriers are, provided that people with disabilities are supported appropriately. In that way, Chris was inspiring, and may have changed the way some of us look at this specific disability that he had, but also other disabilities.”

A bigger picture, indeed.

Gretchen Henkel is a freelance writer in California.

Reference

1. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013;88:224-232.

"What’s the bigger picture here?” Hospitalist Christopher Moreland, MD, MPH, FACP, drops his question neatly into the pause in resident Adrienne Victor, MD’s presentation of patient status and lab results.

We’re on the bustling 9th floor of University Hospital at the University of Texas Health Science Center (UTHSCSA) in San Antonio during fast-paced morning rounds. As attending physician, Dr. Moreland is focusing intently on Dr. Victor’s face, simultaneously monitoring the American Sign Language (ASL) interpretation of Todd Agan, CI/CT, BEI Master Interpreter. Immediately after his question to Dr. Victor, the discussion—conducted in both ASL and spoken English—shifts to the patient’s psychosocial issues and whether a palliative care consult would be advisable.

It’s clear that for Dr. Moreland, the work, not his lack of hearing, is the main point here. A hospitalist with the UTHSCSA team since 2010, Dr. Moreland quickly established himself not only as a valuable HM team member and educator, but also as a leader in other domains. For example, in addition to his academic appointment as assistant clinical professor of medicine, he previously was co-director of the medicine consult and co-management service at University Hospital and now serves as UTHSCSA’s associate program director for the internal medicine residency program.

Dr. Moreland’s question this morning is typical of his teaching, says Bret Simon, PhD, an educational development specialist and assistant professor with the division of hospital medicine at UTHSCSA.

“I grew up working with interpreters, so I’m used to that process. “It forces you to become less inhibited about what you’re doing.”

–Christopher Moreland, MD, MPH, FACP

“He’s very good at using questions to teach, promoting reflection rather than simply telling the student what to do,” Dr. Simon explains.

Why Medicine?

Chris Moreland’s parents discovered their son was deaf at age two, by which time he had acquired very few spoken words. After multiple visits to healthcare professionals, a physician finally identified his deafness. The family then embarked on a bimodal approach to his education, using both signed and spoken English. He learned ASL in college. As a result, he communicates through a variety of channels: ASL with interpreters Agan and Keri Richardson, speech reading, and spoken English. When examining patients, he uses an electronic stethoscope that interfaces with his cochlear implant.

Medicine was not Dr. Moreland’s first academic choice.

“I went into college thinking I wanted to do computer science,” he says, speaking of his undergraduate studies at the University of Texas in Austin. When he realized computers were not for him, he switched his major to theater arts, continuing an interest he had had in high school. After that, research seemed appealing, and he became a research assistant in a lab in the Department of Anthropology. Finally, after shadowing a number of physicians, his interest in medical science was stimulated.

“Medicine,” he says, “became a nice culmination of everything I was interested in doing.” From computer science, he learned to appreciate an understanding of algorithms; from theater arts came the ability to understand where people are coming from; and from his link with research in linguistics and anthropology came the contribution of problem solving and methodology.

Fearless Communicator

Dr. Moreland says his deafness presents no impediments to his practice of medicine. “I grew up working with interpreters, so I’m used to that process,” he says. “It forces you to become less inhibited about what you’re doing. People have questions [‘who is that other person in the room?’], and you learn how to handle those questions quickly, without interfering with communication in order to advance the work.”

When Dr. Moreland started his clinical rotations as a third-year medical student, he grappled with the best way to introduce himself and his interpreter to patients. His first attempt at explaining the interpretive process “went on for quite a while” and was too much information. “It ended up overwhelming the patient,” he says.

The next time he chose not to introduce the interpreter but to simply address the patient directly. “That didn’t work either, because the patient’s eyes kept wandering to that other person in the room.”

Finally, “I realized that it wasn’t about me,” he says. “It was about the patient.” So he simply shortened the introduction to himself and the interpreter and asked the patients how they were doing.

“Once I became more professional about the situation, the more positive and patient-centered it became, and it went well.” He says he’s had no negative experiences since then, at least not related to his deafness. He approaches each new patient interaction proactively, and he and his interpreters become part of the flow of care.

Teaching’s Missing Pieces

As illustrated with his first question, Dr. Moreland intends for his trainees to learn to think globally about their patients.

“Although rote information has its role,” he explains later in the conference room, “I’m always afraid of overemphasizing it. When I trained in medical school, we didn’t learn that much about communication skills and teamwork. We talked a lot about information we use as physicians—the mechanism of disease, the drugs we use.

“What I try to emphasize with trainees is, what skills in communication, teamwork, and self-education can we develop so that we can use those skills continuously throughout our practice?”

Dr. Moreland takes setting resident-generated learning goals seriously, says Dr. Simon, for which he and trainees give him high marks.

“He is very supportive and encourages us to make our own management decisions,” Dr. Victor says. “Though, of course, he will let us know if something is likely the wrong choice, usually by discussing it first.”

Patrick S. Romano, MD, MPH, professor of general medicine and pediatrics and former director of the Primary Care Outcomes Research (PCOR) faculty development program at the University of California Davis, where Dr. Moreland was a resident and then a fellow, found his trainee was always “very thoughtful and conscientious, presenting different ways of looking at problems and asking the right questions. And, of course, that’s what we look for in teachers: people who know how to ask the right questions, because, then, of course, they are able to answer students’ questions.”

Transformational and Inspirational

For many of Dr. Moreland’s colleagues and trainees, working with him has been their first exposure to a hearing-impaired physician. Richard L. Kravitz, MD, MSPH, professor and co-vice chair of research in the department of medicine at UC Davis, supervised Dr. Moreland during his residency and later during his PCOR fellowship. The American Disabilities Act-mandated interpreter for Dr. Moreland introduced a “change in standard operating procedure,” Dr. Kravitz notes. “None of us knew what to expect when he came onboard the residency program. But, very quickly, any unease was put to rest because he was just so talented.”

For visitors, Dr. Moreland seamlessly addresses his hearing impairment and makes sure that everyone on the team is following the discussion. Luci K. Leykum, MD, MBA, MSc, hospital medicine division chief and associate dean for clinical affairs at UTHSCSA, says that Dr. Moreland has brought “a lot of positive energy to the group—and in ways I would not have expected.” She praised his talents as both a clinician and teacher.

John G. Rees, DBA, RN, patient care coordinator in the 5th Acute Care Unit, says that Dr. Moreland immediately “blended” with the staff on his service. “The rapport was perfect,” he adds.

Robert L. Talbert, PharmD, the SmithKline Centennial Professor of Pharmacy at the College of Pharmacy at the University of Texas at Austin, often participates in teaching rounds. Dr. Moreland, he says, “has an excellent fund of knowledge; he’s very rational and evidence-based in decisions he makes. He’s exactly what a physician should be.”

Watching interpreters Agan and Richardson during group meetings, Dr. Leykum believes, has influenced their group dynamics. “On a subtle level, having Chris in the group has made us more aware of how we interact with each other.”

Nilam Soni, MD, FHM associate professor in the department of medicine and leader of ultrasound education, has noticed that he has become attuned to Dr. Moreland’s way of communicating and often does not need the interpreters to decipher the conversation between them. Working with Dr. Moreland has given Dr. Soni “a better understanding of how to communicate effectively with patients that have difficulty hearing.”

After working with Dr. Moreland at UC Davis, Dr. Kravitz observed that employing physicians with hearing impairment or other disabilities brings additional benefits to the institution. Dr. Moreland’s presence “probably raised the level of understanding of the entire internal medicine staff, because it demonstrated that a disability is what you make of it,” he says. “One recognizes how porous the barriers are, provided that people with disabilities are supported appropriately. In that way, Chris was inspiring, and may have changed the way some of us look at this specific disability that he had, but also other disabilities.”

A bigger picture, indeed.

Gretchen Henkel is a freelance writer in California.

Reference

1. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013;88:224-232.

"What’s the bigger picture here?” Hospitalist Christopher Moreland, MD, MPH, FACP, drops his question neatly into the pause in resident Adrienne Victor, MD’s presentation of patient status and lab results.

We’re on the bustling 9th floor of University Hospital at the University of Texas Health Science Center (UTHSCSA) in San Antonio during fast-paced morning rounds. As attending physician, Dr. Moreland is focusing intently on Dr. Victor’s face, simultaneously monitoring the American Sign Language (ASL) interpretation of Todd Agan, CI/CT, BEI Master Interpreter. Immediately after his question to Dr. Victor, the discussion—conducted in both ASL and spoken English—shifts to the patient’s psychosocial issues and whether a palliative care consult would be advisable.

It’s clear that for Dr. Moreland, the work, not his lack of hearing, is the main point here. A hospitalist with the UTHSCSA team since 2010, Dr. Moreland quickly established himself not only as a valuable HM team member and educator, but also as a leader in other domains. For example, in addition to his academic appointment as assistant clinical professor of medicine, he previously was co-director of the medicine consult and co-management service at University Hospital and now serves as UTHSCSA’s associate program director for the internal medicine residency program.

Dr. Moreland’s question this morning is typical of his teaching, says Bret Simon, PhD, an educational development specialist and assistant professor with the division of hospital medicine at UTHSCSA.

“I grew up working with interpreters, so I’m used to that process. “It forces you to become less inhibited about what you’re doing.”

–Christopher Moreland, MD, MPH, FACP

“He’s very good at using questions to teach, promoting reflection rather than simply telling the student what to do,” Dr. Simon explains.

Why Medicine?

Chris Moreland’s parents discovered their son was deaf at age two, by which time he had acquired very few spoken words. After multiple visits to healthcare professionals, a physician finally identified his deafness. The family then embarked on a bimodal approach to his education, using both signed and spoken English. He learned ASL in college. As a result, he communicates through a variety of channels: ASL with interpreters Agan and Keri Richardson, speech reading, and spoken English. When examining patients, he uses an electronic stethoscope that interfaces with his cochlear implant.

Medicine was not Dr. Moreland’s first academic choice.

“I went into college thinking I wanted to do computer science,” he says, speaking of his undergraduate studies at the University of Texas in Austin. When he realized computers were not for him, he switched his major to theater arts, continuing an interest he had had in high school. After that, research seemed appealing, and he became a research assistant in a lab in the Department of Anthropology. Finally, after shadowing a number of physicians, his interest in medical science was stimulated.

“Medicine,” he says, “became a nice culmination of everything I was interested in doing.” From computer science, he learned to appreciate an understanding of algorithms; from theater arts came the ability to understand where people are coming from; and from his link with research in linguistics and anthropology came the contribution of problem solving and methodology.

Fearless Communicator

Dr. Moreland says his deafness presents no impediments to his practice of medicine. “I grew up working with interpreters, so I’m used to that process,” he says. “It forces you to become less inhibited about what you’re doing. People have questions [‘who is that other person in the room?’], and you learn how to handle those questions quickly, without interfering with communication in order to advance the work.”

When Dr. Moreland started his clinical rotations as a third-year medical student, he grappled with the best way to introduce himself and his interpreter to patients. His first attempt at explaining the interpretive process “went on for quite a while” and was too much information. “It ended up overwhelming the patient,” he says.

The next time he chose not to introduce the interpreter but to simply address the patient directly. “That didn’t work either, because the patient’s eyes kept wandering to that other person in the room.”

Finally, “I realized that it wasn’t about me,” he says. “It was about the patient.” So he simply shortened the introduction to himself and the interpreter and asked the patients how they were doing.

“Once I became more professional about the situation, the more positive and patient-centered it became, and it went well.” He says he’s had no negative experiences since then, at least not related to his deafness. He approaches each new patient interaction proactively, and he and his interpreters become part of the flow of care.

Teaching’s Missing Pieces

As illustrated with his first question, Dr. Moreland intends for his trainees to learn to think globally about their patients.

“Although rote information has its role,” he explains later in the conference room, “I’m always afraid of overemphasizing it. When I trained in medical school, we didn’t learn that much about communication skills and teamwork. We talked a lot about information we use as physicians—the mechanism of disease, the drugs we use.

“What I try to emphasize with trainees is, what skills in communication, teamwork, and self-education can we develop so that we can use those skills continuously throughout our practice?”

Dr. Moreland takes setting resident-generated learning goals seriously, says Dr. Simon, for which he and trainees give him high marks.

“He is very supportive and encourages us to make our own management decisions,” Dr. Victor says. “Though, of course, he will let us know if something is likely the wrong choice, usually by discussing it first.”

Patrick S. Romano, MD, MPH, professor of general medicine and pediatrics and former director of the Primary Care Outcomes Research (PCOR) faculty development program at the University of California Davis, where Dr. Moreland was a resident and then a fellow, found his trainee was always “very thoughtful and conscientious, presenting different ways of looking at problems and asking the right questions. And, of course, that’s what we look for in teachers: people who know how to ask the right questions, because, then, of course, they are able to answer students’ questions.”

Transformational and Inspirational

For many of Dr. Moreland’s colleagues and trainees, working with him has been their first exposure to a hearing-impaired physician. Richard L. Kravitz, MD, MSPH, professor and co-vice chair of research in the department of medicine at UC Davis, supervised Dr. Moreland during his residency and later during his PCOR fellowship. The American Disabilities Act-mandated interpreter for Dr. Moreland introduced a “change in standard operating procedure,” Dr. Kravitz notes. “None of us knew what to expect when he came onboard the residency program. But, very quickly, any unease was put to rest because he was just so talented.”

For visitors, Dr. Moreland seamlessly addresses his hearing impairment and makes sure that everyone on the team is following the discussion. Luci K. Leykum, MD, MBA, MSc, hospital medicine division chief and associate dean for clinical affairs at UTHSCSA, says that Dr. Moreland has brought “a lot of positive energy to the group—and in ways I would not have expected.” She praised his talents as both a clinician and teacher.

John G. Rees, DBA, RN, patient care coordinator in the 5th Acute Care Unit, says that Dr. Moreland immediately “blended” with the staff on his service. “The rapport was perfect,” he adds.

Robert L. Talbert, PharmD, the SmithKline Centennial Professor of Pharmacy at the College of Pharmacy at the University of Texas at Austin, often participates in teaching rounds. Dr. Moreland, he says, “has an excellent fund of knowledge; he’s very rational and evidence-based in decisions he makes. He’s exactly what a physician should be.”

Watching interpreters Agan and Richardson during group meetings, Dr. Leykum believes, has influenced their group dynamics. “On a subtle level, having Chris in the group has made us more aware of how we interact with each other.”

Nilam Soni, MD, FHM associate professor in the department of medicine and leader of ultrasound education, has noticed that he has become attuned to Dr. Moreland’s way of communicating and often does not need the interpreters to decipher the conversation between them. Working with Dr. Moreland has given Dr. Soni “a better understanding of how to communicate effectively with patients that have difficulty hearing.”

After working with Dr. Moreland at UC Davis, Dr. Kravitz observed that employing physicians with hearing impairment or other disabilities brings additional benefits to the institution. Dr. Moreland’s presence “probably raised the level of understanding of the entire internal medicine staff, because it demonstrated that a disability is what you make of it,” he says. “One recognizes how porous the barriers are, provided that people with disabilities are supported appropriately. In that way, Chris was inspiring, and may have changed the way some of us look at this specific disability that he had, but also other disabilities.”

A bigger picture, indeed.

Gretchen Henkel is a freelance writer in California.

Reference

1. Moreland CJ, Latimore D, Sen A, Arato N, Zazove P. Deafness among physicians and trainees: a national survey. Acad Med. 2013;88:224-232.

Dollar value of uncompensated care provided by U.S. hospitals in 2012, expressed in terms of actual costs, according to data from the American Hospital Association’s Annual Survey of Hospitals^.6 This figure represents 6.1% of total costs, an increase of 11.7% from 2011. The total includes both bad debt and charity care provided to patients unable to pay for their care, AHA says, but does not include underpayments by Medicare and Medicaid.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

Dollar value of uncompensated care provided by U.S. hospitals in 2012, expressed in terms of actual costs, according to data from the American Hospital Association’s Annual Survey of Hospitals^.6 This figure represents 6.1% of total costs, an increase of 11.7% from 2011. The total includes both bad debt and charity care provided to patients unable to pay for their care, AHA says, but does not include underpayments by Medicare and Medicaid.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

Dollar value of uncompensated care provided by U.S. hospitals in 2012, expressed in terms of actual costs, according to data from the American Hospital Association’s Annual Survey of Hospitals^.6 This figure represents 6.1% of total costs, an increase of 11.7% from 2011. The total includes both bad debt and charity care provided to patients unable to pay for their care, AHA says, but does not include underpayments by Medicare and Medicaid.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

The Philadelphia Inquirer recently reported that Holy Redeemer Hospital in Meadowbrook, Pa., cut its incidence of Clostridium difficile by two-thirds after its nutritionists began encouraging hospitalized patients with orders for antibiotics for more than one day to eat a widely available brand of yogurt.² Seventy-five C. diff cases were reported in the hospital during 2011 and only 23 in 2012. The facility won an innovation award for the program from the Hospital and Healthsystem Association of Pennsylvania.

Other hospitals dispense probiotic dietary supplements, shown to have benefits against C. diff, in granular form. Medical experts have expressed skepticism that dispensing yogurt made the difference in cutting C. diff infections, arguing that there has not been enough research yet to support its widespread implementation in hospital settings.

Nationally, 337,000 cases of C. diff are reported in hospitals each year. A recent study reports that its spores are still commonly carried on the hands of healthcare workers who rubbed alcohol on their hands shortly after providing routine care to patients.³ Risk factors independently associated with hand contamination among healthcare workers in the exposed group included high-risk contacts and at least one contact without the use of gloves.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

The Philadelphia Inquirer recently reported that Holy Redeemer Hospital in Meadowbrook, Pa., cut its incidence of Clostridium difficile by two-thirds after its nutritionists began encouraging hospitalized patients with orders for antibiotics for more than one day to eat a widely available brand of yogurt.² Seventy-five C. diff cases were reported in the hospital during 2011 and only 23 in 2012. The facility won an innovation award for the program from the Hospital and Healthsystem Association of Pennsylvania.

Other hospitals dispense probiotic dietary supplements, shown to have benefits against C. diff, in granular form. Medical experts have expressed skepticism that dispensing yogurt made the difference in cutting C. diff infections, arguing that there has not been enough research yet to support its widespread implementation in hospital settings.

Nationally, 337,000 cases of C. diff are reported in hospitals each year. A recent study reports that its spores are still commonly carried on the hands of healthcare workers who rubbed alcohol on their hands shortly after providing routine care to patients.³ Risk factors independently associated with hand contamination among healthcare workers in the exposed group included high-risk contacts and at least one contact without the use of gloves.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.

The Philadelphia Inquirer recently reported that Holy Redeemer Hospital in Meadowbrook, Pa., cut its incidence of Clostridium difficile by two-thirds after its nutritionists began encouraging hospitalized patients with orders for antibiotics for more than one day to eat a widely available brand of yogurt.² Seventy-five C. diff cases were reported in the hospital during 2011 and only 23 in 2012. The facility won an innovation award for the program from the Hospital and Healthsystem Association of Pennsylvania.

Other hospitals dispense probiotic dietary supplements, shown to have benefits against C. diff, in granular form. Medical experts have expressed skepticism that dispensing yogurt made the difference in cutting C. diff infections, arguing that there has not been enough research yet to support its widespread implementation in hospital settings.

Nationally, 337,000 cases of C. diff are reported in hospitals each year. A recent study reports that its spores are still commonly carried on the hands of healthcare workers who rubbed alcohol on their hands shortly after providing routine care to patients.³ Risk factors independently associated with hand contamination among healthcare workers in the exposed group included high-risk contacts and at least one contact without the use of gloves.

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life's end in inpatient settings: The BEACON trial. J Gen Intern Med. 2014;29(6):836-843.
2. Burling S. Yogurt a solution to hospital infection? Philadelphia Inquirer website. December 10, 2013. Available at: http://articles.philly.com/2013-12-10/news/44946926_1_holy-redeemer-probiotics-yogurt. Accessed June 5, 2014.
3. Landelle C, Verachten M, Legrand P, Girou E, Barbut F, Buisson CB. Contamination of healthcare workers’ hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol. 2014;35(1):10-15.
4. Lewis K, Walker C. Development and application of information technology solutions to improve the quality and availability of discharge summaries. Journal of Hospital Medicine RIV abstracts website. Available at: http://www.shmabstracts.com/abstract.asp?MeetingID=793&id=104276&meeting=JHM201305. Published May 2013. Accessed June 14, 2014.
5. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement. American College of Physicians; Society of General Internal Medicine; Society of Hospital Medicine; American Geriatrics Society; American College of Emergency Physicians; Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
6. American Hospital Association: Uncompensated hospital care cost fact sheet. January 2014. Available at: http://www.aha.org/content/14/14uncompensatedcare.pdf. Accessed June 5, 2014.