Hospitalists' perceptions of their residency training needs: results of a national survey

A Novel Hospital Medicine Training Track for Internal Medicine Residents: Description and Program Evaluation of the First 15 Years

BACKGROUND

The growth of hospital medicine has resulted in a parallel growth of hospital medicine training within internal medicine residency programs (IMRPs), but the experience and outcomes of these training offerings have not yet been described.

OBJECTIVE

To describe the first dedicated hospitalist track and the program evaluation data.

METHODS

The University of Colorado Hospitalist Training Track (HTT) is a 3-year track within the IMRP with robust inpatient clinical training, specialized didactics, experiential improvement work, and career mentorship. We collected data on graduates' current practices and board certification pass rates. To further evaluate the track, we electronically sent a cross-sectional survey to 124 graduates from 2005 to 2019 to identify current practice settings, graduate roles, and assessment of the training track.

RESULTS

Among 124 graduates, 97 (78.2%) practice hospital medicine, and the board certification pass rate was slightly higher than the overall IMRP pass rate for those graduating classes. Sixty-two (50%) graduates responded to the survey. Among respondents, 50 (80.6%) currently practice hospital medicine and 34 (54.8%) practice in an academic setting. The majority (50, 80.6%) hold leadership roles and are involved in a variety of scholarship, educational, and operational projects. Dedicated clinical training, didactics, and mentorship were valued by respondents.

CONCLUSIONS

This represents the first description and program evaluation of a HTT for IM residents. A dedicated HTT produces graduates who choose hospital medicine careers at high rates and participate in a wide variety of leadership and nonclinical roles.

Rates and Characteristics of Medical Malpractice Claims Against Hospitalists

BACKGROUND

Hospitalists practice in high-stakes and litigious settings. However, little data exist about the malpractice claims risk faced by hospitalists.

OBJECTIVE

To characterize the rates and characteristics of malpractice claims against hospitalists.

DESIGN, SETTING, AND PARTICIPANTS

An analysis was performed of malpractice claims against hospitalists, as well as against select other specialties, using data from a malpractice claims database that includes approximately 31% of US malpractice claims.

MAIN OUTCOMES AND MEASURES

For malpractice claims against hospitalists (n = 1,216) and comparator specialties (n = 18,644): claims rates (using a data subset), percentage of claims paid, median indemnity payment amounts, allegation types, and injury severity.

RESULTS

Hospitalists had an annual malpractice claims rate of 1.95 claims per 100 physician-years, similar to that of nonhospitalist general internal medicine physicians (1.92 claims per 100 physician-years), and significantly greater than that of internal medicine subspecialists (1.30 claims per 100 physician-years) (P < .001). Claims rates for hospitalists nonsignificantly increased during the study period (2009-2018), whereas claims rates for four of the five other specialties examined significantly decreased over this period. The median indemnity payment for hospitalist claims was $231,454 (interquartile range, $100,000-$503,015), significantly higher than the amounts for all the other specialties except neurosurgery. The greatest predictor of a hospitalist case closing with payment (compared with no payment) was an error in clinical judgment as a contributing factor, with an adjusted odds ratio of 5.01 (95% CI, 3.37-7.45).

CONCLUSION

During the study period, hospitalist claims rates did not drop, whereas they fell for other specialties. Hospitalists' claims had relatively high injury severity and median indemnity payment amounts. The malpractice environment for hospitalists is becoming less favorable.

Phobia among residents in board training programs in Abha, Kingdom of Saudi Arabia, 2019

Background:

Phobia is an extreme form of anxiety or fear which is triggered by a given situation or object or even danger associated with a situation or object for more than 6 months. There are three main forms of phobia: social phobia (social anxiety disorder), specific phobia, or agoraphobia. Agoraphobia is a form of anxiety disorder where one fears and avoids situations or places that might cause them to panic. The main purpose of this study is to investigate phobia among residents in broad training programs in Abha city and compare phobia between residents in broad training programs and general practitioners in Abha city.

Methods:

It is a cross-sectional study. The study was conducted in Abha city of Saudi Arabia from December 2019 to March 2020. It included a representative sample of medical doctors under broad training programs and general practitioners (none trained) in all the health-care centers. A link for the survey questionnaires was created and shared with the respondents. The questionnaire included sociodemographics of the participants, the Kutcher Generalized Social Anxiety Disorder Scale, and the Psychometric Properties and Clinical Utility of the Specific Phobia Questionnaire in an Anxiety Disorders Sample for specific phobia.

Results:

The study included 300 physicians. Majority of them (81%) were in the age group between 25 and 30 years. Males represent 54% of them. There was no statistically significant difference between resident physicians and general practitioners regarding the avoidance of different social situations.

Conclusion:

Overall, the residents in board training programs in Abha city expressed lower levels of discomfort, anxiety, distress, avoidance, fear, and life interference of some social and specific situations compared to general practitioners.

Teaching Ethics and Professionalism: A National Survey of Ophthalmology Residency Program Directors

Background While ethics and professionalism are important components of graduate medical education, there is limited data about how ethics and professionalism curricula are taught or assessed in ophthalmology residency programs.

Objective This study aimed to determine how U.S. ophthalmology residency programs teach and assess ethics and professionalism and explore trainee preparedness in these areas.

Methods Directors from accredited U.S. ophthalmology residency programs completed an online survey about components of programs' ethics and professionalism teaching curricula, strategies for assessing competence, and trainee preparedness in these areas.

Results Directors from 55 of 116 programs (46%) responded. The most common ethics and professionalism topics taught were informed consent (38/49, 78%) and risk management and litigation (38/49, 78%), respectively; most programs assessed trainee competence via 360-degree global evaluation (36/48, 75%). While most (46/48, 95%) respondents reported that their trainees were well or very well prepared at the time of graduation, 15 of 48 (31%) had prohibited a trainee from graduating or required remediation prior to graduation due to unethical or unprofessional conduct. Nearly every program (37/48, 98%) thought that it was very important to dedicate curricular time to teaching ethics and professionalism. Overall, 16 of 48 respondents (33%) felt that the time spent teaching these topics was too little.

Conclusion Ophthalmology residency program directors recognized the importance of an ethics and professionalism curriculum. However, there was marked variation in teaching and assessment methods. Additional work is necessary to identify optimal strategies for teaching and assessing competence in these areas. In addition, a substantial number of trainees were prohibited from graduating or required remediation due to ethics and professionalism issues, suggesting an impact of unethical and unprofessional behavior on resident attrition.

Clinical and Financial Implications of Consulting Physicians in the Management of Surgical Patients

BACKGROUND

The present study was designed to evaluate the immediate consequences that the number of consulting physicians has on length of stay (LOS), in-hospital mortality, 30-day readmission rates, direct health care costs, and contribution margins.

METHODS

A retrospective review of administrative databases for the years 2013 and 2014 was performed at the Florida Hospital Adventist Healthcare System.

RESULTS

11 274 patients were included in the analysis. Total and variable costs increased by $1347 and $592, respectively, with each consulting physician service per patient. The contribution margin decreased by $354 per patient/consulting physician. Each consulting physician increased LOS by .72 days and increased odds ratio of mortality and 30-day readmission by 5% and 3%, respectively.

CONCLUSIONS

Our research suggests that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, in-hospital mortality, and costs.

Hospitalist and Intensivist Experiences of the "Open" Intensive Care Unit Environment: a Qualitative Exploration

BACKGROUND

Most U.S. academic medical centers employ "closed" intensive care units (ICUs), where critically ill patients are admitted under the supervision of intensivists managing dedicated ICU teams. Some centers utilize a unique "open" ICU structure, where primary services longitudinally follow patients who become critically ill into the ICU with intensivist comanagement. The impact of open ICUs on patient care and education of trainees has not been well-characterized.

OBJECTIVE

The objective of this study is to characterize affordances and barriers to education and patient care, from the perspectives of hospitalists and intensivists teaching in the ICU.

DESIGN

We conducted semi-structured interviews with hospitalist and intensivist faculty at a large academic medical center with an open ICU structure. We coded deidentified interview transcripts to inductively analyze the data for themes and subthemes.

PARTICIPANTS

We recruited hospitalist and intensivist faculty members who attend on teaching services in the open ICU system.

APPROACH

Given the complexity of multiple teachers and learners in the ICU environment, we selected shared mental models as our primary theoretical lens through which we analyzed and interpreted our data.

KEY RESULTS

We identified three main themes regarding education in the open ICU system: (1) communication challenges, (2) educational barriers and affordances, and (3) structural barriers and affordances. Hospitalists and intensivists agreed on some barriers and facilitators to education, such as continuity of care, yet they disagreed on others. Specifically, hospitalists and intensivists had a shared mental model regarding barriers to patient care and education in the open ICU structure, but had divergent opinions regarding the affordances of the structure, such as continuity and availability of ICU expertise.

CONCLUSIONS

The open ICU environment presents facilitators and barriers to trainee education and patient care. Our findings can be leveraged to improve communication, education, and patient care on both hospitalist and ICU teams.

Top Qualifications Hospitalist Leaders Seek in Candidates: Results from a National Survey

Despite rapidly growing interest in Hospital Medicine (HM), no prior research has examined the factors that may be most beneficial or detrimental to candidates during the HM hiring process. We developed a survey instrument to assess how those involved in the HM hiring process assess HM candidate attributes, skills and behaviors. The survey was distributed electronically to nontrainee physician Society of Hospital Medicine members. Respondents ranked the top five qualifications of HM candidates and the top five qualities an HM candidate should demonstrate on interview day to be considered for hiring. In thematic analysis of free-response questions, several themes emerged relating to interview techniques and recruitment strategies, including heterogeneous approaches to long-term versus short-term applicants. These findings represent the first published assessment in the area of HM hiring and should inform HM candidates and their mentors.

Training Residents in Hospital Medicine: The Hospitalist Elective National Survey

As the field of hospital medicine expands, internal medicine residency programs can play a role in preparing future hospitalists. To date, little is known of the prevalence and characteristics of hospitalist-focused resident rotations. We surveyed the largest 100 Internal Medicine Residency Programs to better understand the prevalence, objectives, and structure of hospitalist-focused rotations in the United States. Residency leaders from 82 programs responded (82%). The prevalence of hospitalist-focused rotations was 50% (41/82) with an additional 9 programs (11%) planning to start one. Of these 41 rotations, 85% were elective rotations and 15% were mandatory rotations. Rotations involved clinical responsibilities, and most programs incorporated nonclinical curricular activities such as teaching, research, and work on quality improvement and patient safety. Respondents noted that their programs promoted autonomy, mentorship, and "real-world" hospitalist experience. Hospitalist-focused rotations may supplement traditional inpatient rotations and teach skills that facilitate the transition from residency to a career in hospital medicine.

Primary Palliative Care Education: A Pilot Survey

The demand for palliative services is outpacing the availability of specialist palliative care clinicians. One strategy to fill this gap is to improve "primary palliative care" skills and knowledge of all clinicians who care for seriously ill patients. Previous educational efforts have shown mixed results, and one possible explanation is unrecognized discordance of educational goals between those offering education and potential primary palliative care learners. The article describes the results and feasibility of a needs assessment survey comparing interest in palliative care education topics and settings among both palliative care specialists (PCS) and nonpalliative care specialists (NPCS). This is the first attempt to measure the perceived importance of primary palliative care topics and preferences about learning settings from the perspectives of both NPCS and PCS. The results suggest substantial areas of both concordant and discordant opinions with respect to educational topics and learning settings. Such data are essential to guide primary palliative care educational efforts. Future work will be needed to determine whether these results are consistent across diverse health systems and what variables influence educational preferences.

A resident-created hospitalist curriculum for internal medicine housestaff

The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016;11:646-649. © 2016 Society of Hospital Medicine.

A Nationwide Analysis of Outcomes of Weekend Admissions for Intracerebral Hemorrhage Shows Disparities Based on Hospital Teaching Status

BACKGROUND AND PURPOSE

With the "weekend effect" being well described, the Brain Attack Coalition released a set of "best practice" guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a "weekend effect" in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect.

MATERIALS AND METHODS

We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States.

RESULTS

Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care.

CONCLUSION

Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.

Integration of Palliative Care Services in the Intensive Care Unit: A Roadmap for Overcoming Barriers

Clinicians working in the intensive care unit (ICU) confront death and dying daily. ICU care can be inconsistent with a patient's values, preferences, and previously expressed goals of care. Current evidence promotes the integration of palliative care services within the ICU setting. Palliative care bridges the gap between comfort and cure, and these services are growing in the United States. This article discusses the benefits and barriers to integration of ICU and palliative care services, and a stepwise approach to implementation of palliative care services. Integration of palliative care services into ICU workflow is increasingly seen as essential to providing high-quality, comprehensive critical care.

Perceived core competency achievements of fellowship and non-fellowship-trained early career pediatric hospitalists

BACKGROUND

The pediatric hospital medicine (PHM) core competencies were established in 2010 to identify the specific knowledge base and skill set needed to provide the highest quality of care for hospitalized children. The objectives of this study were to examine the perceived core competency achievements of fellowship-trained and non-fellowship-trained early career pediatric hospitalists and identify perceived gaps in our current training models.

METHODS

An anonymous Web-based survey was distributed in November 2013. Hospitalists within 5 years of their residency graduation reported their perceived competency in select PHM core competencies. χ(2) and multiprobit regression analyses were utilized.

RESULTS

One hundred ninety-seven hospitalists completed the survey and were included; 147 were non-fellowship-trained and 50 were PHM fellowship graduates or current PHM fellows. Both groups reported feeling less than competent in sedation and aspects of business practice. Non-fellowship-trained hospitalists also reported mean scores in the less than competent range in intravenous access/phlebotomy, technology-dependent emergencies, performing Plan-Do-Study-Act process and root cause analysis, defining basic statistical terms, and identifying research resources. Non-fellowship-trained hospitalists reported mean competency scores greater than fellowship-trained hospitalists in pain management, newborn care, and transitions in care.

CONCLUSIONS

Early career pediatric hospitalists report deficits in several of the PHM core competencies, which should be considered when designing PHM-specific training in the future. Fellowship-trained hospitalists report higher levels of perceived competency in many core areas.

Pediatric hospital medicine role in the comanagement of the hospitalized surgical patient

Medical comanagement of surgical patients by pediatric hospital medicine providers has become increasingly common. Subjectively, the comanagement model is superior to more traditional consultative models because of the anticipatory preventive care and coordination hospitalists provide to patients and hospital colleagues. Although some studies have demonstrated the value of the comanagement model in adults and children, others have failed to do so. The coming years are both exciting and challenging for this emerging field as it attempts to sustain its early progress and define its future in pediatric hospital medicine.

Hospitalist career decisions among internal medicine residents

BACKGROUND

Hospital medicine is a rapidly growing field of internal medicine. However, little is known about internal medicine residents' decisions to pursue careers in hospital medicine (HM).

OBJECTIVE

To identify which internal medicine residents choose a career in HM, and describe changes in this career choice over the course of their residency education.

DESIGN

Observational cohort using data collected from the annual Internal Medicine In-Training Examination (IM-ITE) survey.

PARTICIPANTS

16,781 postgraduate year 3 (PGY-3) North American internal medicine residents who completed the annual IM-ITE survey in 2009-2011, 9,501 of whom completed the survey in all 3 years of residency.

MAIN MEASURES

Self-reported career plans for individual residents during their postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2) and PGY-3.

KEY RESULTS

Of the 16,781 graduating PGY-3 residents, 1,552 (9.3 %) reported HM as their ultimate career choice. Of the 951 PGY-3 residents planning a HM career among the 9,501 residents responding in all 3 years, 128 (13.5 %) originally made this decision in PGY-1, 192 (20.2 %) in PGY-2, and 631 (66.4 %) in PGY-3. Only 87 (9.1 %) of these 951 residents maintained a career decision of HM during all three years of residency education.

CONCLUSIONS

Hospital medicine is a reported career choice for an important proportion of graduating internal medicine residents. However, the majority of residents do not finalize this decision until their final year.

Dancing around death: hospitalist-patient communication about serious illness

Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient's understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.

Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies

Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency. Hospital leaders have stated they expect hospitalists to comanage surgical patients, participate in observation units, and screen medical admissions, in addition to providing inpatient care for medical patients. We review how the hospitalists' role in acute inpatient care, surgical comanagement, short stay units, chest pain units, and active bed management has improved throughput and patient flow.

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture.

Hospital quality and patient safety competencies: development, description, and recommendations for use

BACKGROUND

Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally emphasized healthcare quality and patient safety in their curricula.

METHODS

Through a multistep process, the Society of Hospital Medicine (SHM) Quality Improvement Education (QIE) subcommittee developed the Hospital Quality and Patient Safety (HQPS) Competencies to provide a framework for developing and assessing curricula and other professional development experiences. This article describes the development, provides definitions, and makes recommendations on the use of the HQPS Competencies.

RESULTS

The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Reflecting differing levels of hospitalist involvement in healthcare quality, 3 levels of expertise within each area of competence have been established: basic, intermediate, and advanced. Standards for each competency area use carefully selected action verbs to reflect educational goals for hospitalists at each level.

CONCLUSIONS

Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.

Code status discussions between attending hospitalist physicians and medical patients at hospital admission

BACKGROUND

Bioethicists and professional associations give specific recommendations for discussing cardiopulmonary resuscitation (CPR).

OBJECTIVE

To determine whether attending hospitalist physicians' discussions meet these recommendations.

DESIGN

Cross-sectional observational study on the medical services at two hospitals within a university system between August 2008 and March 2009.

PARTICIPANTS

Attending hospitalist physicians and patients who were able to communicate verbally about their medical care.

MAIN MEASURES

We identified code status discussions in audio-recorded admission encounters via physician survey and review of encounter transcripts. A quantitative content analysis was performed to determine whether discussions included elements recommended by bioethicists and professional associations. Two coders independently coded all discussions; Cohen's kappa was 0.64-1 for all reported elements.

KEY RESULTS

Audio-recordings of 80 patients' admission encounters with 27 physicians were obtained. Eleven physicians discussed code status in 19 encounters. Discussions were more frequent in seriously ill patients (OR 4, 95% CI 1.2-14.6), yet 66% of seriously ill patients had no discussion. The median length of the code status discussions was 1 min (range 0.2-8.2). Prognosis was discussed with code status in only one of the encounters. Discussions of patients' preferences focused on the use of life-sustaining interventions as opposed to larger life goals. Descriptions of CPR as an intervention used medical jargon, and the indication for CPR was framed in general, as opposed to patient-specific scenarios. No physician quantitatively estimated the outcome of or provided a recommendation about the use of CPR.

CONCLUSIONS

Code status was not discussed with many seriously ill patients. Discussions were brief, and did not include elements that bioethicists and professional associations recommend to promote patient autonomy. Local and national guidelines, research, and clinical practice changes are needed to clarify and systematize with whom and how CPR is discussed at hospital admission.

The role of hospitalists in the acute care of stroke patients

Stroke care has become progressively more complicated with advances in therapies necessitating timely intervention. There are multiple potential providers of stroke care, which traditionally has been the province of general neurologists and primary care physicians. These new players, be they vascular neurologists, neurohospitalists, internal medicine hospitalists, or neurocritical care physicians, at the bedside or at a distance, are poised to make a significant impact on our care of stroke patients. The collaborative model of care may be or become the most prevalent as physicians apply their distinct skill sets to the complex care of inpatients with cerebrovascular disease.

Comanagement of hospitalized surgical patients by medicine physicians in the United States

BACKGROUND

Comanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes. We examined the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States.

METHODS

We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for 1 of 15 inpatient surgical procedures from 1996 to 2006 (n = 694 806). We also calculated the proportion of Medicare beneficiaries comanaged by medicine physicians (generalist physicians or internal medicine subspecialists) during hospitalization. Comanagement was defined by relevant physicians (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patients were hospitalized.

RESULTS

Between 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by a medicine physician: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). The percentage of patients experiencing comanagement was relatively unchanged from 1996 to 2000 and then increased sharply. The increase was entirely attributable to a surge in comanagement by generalist physicians. In a multivariable multilevel analysis, comanagement by generalist physicians increased 11.4% per year from 2001 to 2006. Patients with advanced age, with more comorbidities, or receiving care in nonteaching, midsize (200-499 beds), or for-profit hospitals were more likely to receive comanagement. All of the growth in comanagement was attributed to increased comanagement by hospitalist physicians.

CONCLUSIONS

Medical comanagement of Medicare beneficiaries hospitalized for a surgical procedure is increasing because of the increasing role of hospitalists. To meet this growing need for comanagement, training in internal medicine should include medical management of surgical patients.

Expanding the paradigm of the physician's role in surrogate decision-making: an empirically derived framework

BACKGROUND

Little is known about what role physicians take in the decision-making process about life support in intensive care units.

OBJECTIVE

To determine how responsibility is balanced between physicians and surrogates for life support decisions and to empirically develop a framework to describe different models of physician involvement.

DESIGN

Multi-centered study of audio-taped clinician-family conferences with a derivation and validation cohort.

SETTING

Intensive care units of four hospitals in Seattle, Washington, in 2000 to 2002 and two hospitals in San Francisco, California, in 2006 to 2008.

PARTICIPANTS

Four hundred fourteen clinicians and 495 surrogates who were involved in 162 life support decisions.

RESULTS

In the derivation cohort (n = 63 decisions), no clinician inquired about surrogates' preferred role in decision-making. Physicians took one of four distinct roles: 1) informative role (7 of 63) in which the physician provided information about the patient's medical condition, prognosis, and treatment options but did not elicit information about the patient's values, engage in deliberations, or provide a recommendation about whether to continue life support; 2) facilitative role (23 of 63), in which the physician refrained from providing a recommendation but actively guided the surrogate through a process of clarifying the patients' values and applying those values to the decision; 3) collaborative role (32 of 63), in which the physician shared in deliberations with the family and provided a recommendation; and 4) directive role (1 of 63), in which the physician assumed all responsibility for, and informed the family of, the decision. In 10 out of 20 conferences in which surrogates requested a recommendation, the physician refused to provide one. The validation cohort revealed a similar frequency of use of the four roles, and frequent refusal by physicians to provide treatment recommendations.

CONCLUSIONS

There is considerable variability in the roles physicians take in decision-making about life support with surrogates but little negotiation of desired roles. We present an empirically derived framework that provides a more comprehensive view of physicians' possible roles.

Internal medicine residency graduates' perceptions of the systems-based practice and practice-based learning and improvement competencies

BACKGROUND

Resident education in Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI) is required but underemphasized.

PURPOSES

The objectives are to identify SBP and PBLI knowledge and skills with the most relevance to our graduates' practices and to determine how well they were prepared during residency training to address these issues.

METHODS

A survey was drafted based on Accreditation Council for Graduate Medical Education competency definitions and published literature on SBP and PBLI. Respondents indicated the extent to which each item is relevant to their practice and the adequacy of instruction received on a 5-point Likert scale.

RESULTS

All topics had high perceived relevance to practice with most topics rated low for adequacy of training. Topics of practice management and health care economics contained the largest gaps between mean ratings of relevance and adequacy of training (p < .001). Few differences in ratings were seen based on graduate demographics.

CONCLUSIONS

This survey has allowed us to prioritize SBP and PBLI curricula to meet the needs of our graduates.

California hospital leaders' views of hospitalists: meeting needs of the present and future

BACKGROUND

Hospital medicine has grown rapidly, but hospital leaders' perceptions of current and future drivers of hospitalist growth are unknown.

OBJECTIVE

: To determine hospital executives' perceptions of factors leading to hospitalist implementation and their vision for hospitalists' work roles.

SETTING

Nonfederal, acute care hospitals in California.

PARTICIPANTS

California hospital leaders (eg, chief executive officers).

INTERVENTION

Cross-sectional survey from 2006 to 2007.

MEASUREMENTS

We asked California hospital leaders whether their hospitals had a hospitalist service and the prospects for growth. In addition, we examined factors responsible for implementation, scope of hospitalists' practices, and need for additional certification as perceived by hospital leaders.

RESULTS

We received surveys from 179 of 334 hospitals (response rate of 54%). Of the 64% of respondents that reported the use of hospitalists, none intended to decrease the size of their hospitalist group, and 57% expected growth over 2 years. The most common reasons for implementing a hospitalist program were to care for uncovered patients (68%) and improve cost/length of stay (63%). Respondents also indicated that demand from other physicians was an important factor. Leaders reported that hospitalists provide a wide range of services, with a majority involved in quality improvement projects (72%) and medical comanagement of surgical patients (66%). Most leaders favor additional certification for hospitalists.

CONCLUSIONS

There is widespread adoption of hospitalists in California hospitals, with an expectation of continued growth. The drivers of the field's growth are evolving and dynamic. In particular, attentiveness to quality performance and demand from other physicians are increasingly important reasons for implementation.

A case-based teaching module combined with audit and feedback to improve the quality of consultations

BACKGROUND

Medical consultation is an integral part of hospitalist physicians' practice, yet there is no uniform training to achieve competency in this area during residency.

OBJECTIVE

To improve the quality of medical consultations performed by hospitalists in an academic medical center.

DESIGN

Single group pre-post study design comparing knowledge and behaviors after exposing physicians to an educational intervention.

SETTING

Johns Hopkins Bayview Medical Center, 2006-2007.

PARTICIPANTS

Seven hospitalist faculty members, and 12 internal medicine house-staff members, who served on the medical consultation service during the study period.

INTERVENTION

Participants were exposed to an educational intervention consisting of a case-based module teaching the principles of medical consultation, as well as audit and feedback in which they critically reviewed their most recent written consultations.

MEASUREMENTS

Pretests and posttests were used to assess knowledge. Performance and physician behaviors were assessed following the intervention; consultations done by hospitalists in the months prior to the educational intervention were scored and compared to their postintervention consultations. Wilcoxon signed rank tests and paired t tests were used for the analyses.

RESULTS

Improvement in the median knowledge score (pretest vs. posttest) was significant only for house-staff and not for faculty (10/14 vs. 12/14, P = 0.03 and 11/14 vs. 12/14, P = 0.08, respectively). The quality of consults written by all hospitalists improved after the educational intervention; the mean scores increased from 2.7 to 3.3 (P = 0.0006).

CONCLUSIONS

This curricular intervention including audit and feedback was effective in improving the quality of medical consultations performed by hospitalist physicians.

The impact of adding 1 month of intensive care unit training in a categorical internal medicine residency program

OBJECTIVE

To determine the impact of adding a month of critical care training in the postgraduate year (PGY)-2 on the critical care skills of PGY-3 residents.

DESIGN

Prospective, nonrandomized.

SETTING

The internal medicine (IM) residency program of a tertiary care medical center.

STUDY SUBJECTS

The study subjects included the 2005/2006 and 2006/2007 academic year IM residents.

INTERVENTIONS

The 2005/2006 IM residents (control group, n = 48) had 1 month of critical care training (internship year) before their 1-month PGY-3 rotations. The 2006/2007 residents (intervention group, n = 47) had an additional 1-month rotation in a multispecialty intensive care unit (ICU) during their second year.

MEASUREMENTS AND MAIN RESULTS

At the beginning of their last ICU month rotation, the intervention group's self-assessment (1-5 Likert scale) of their skills in internal jugular venous catheterization (3.4 vs. 2.4, p < 0.001) and management of severe sepsis (4.0 vs. 2.4, p < 0.001) and acute lung injury (3.3 vs. 2.6, p < 0.001) was higher than that of the control group. However, the observed success rates of endotracheal intubation (55.4% vs. 54.9%, p = 0.953) and central venous catheterization (78.1% vs. 80.8%, p = 0.488) were similar between the two groups. No difference was noted in the complication rates for endotracheal intubation or central venous catheterization between the control and intervention groups. End of ICU rotation examination results, attending evaluations, and the observed application of evidence-based practice in the management of severe sepsis were similar between the two groups.

CONCLUSIONS

Increasing IM residents' experience in the ICU resulted in modest, transient improvement of their perceived clinical skills in critical care procedures and management of severe sepsis and acute lung injury. However, no statistically significant and sustained improvement was noted in the observed cognitive or clinical skills.

Pediatric hospitalists: training, current practice, and career goals

OBJECTIVE

To determine the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans of practicing pediatric hospitalists.

DESIGN

Mail survey study of a national sample of 530 pediatric hospitalists of whom 67% (N = 338) were from teaching hospitals, 71% (N = 374) were from children's hospitals, 43% (N = 230) were from freestanding children's hospitals, and 69% (N = 354) were from hospitals with >or=250 beds.

RESULTS

The response rate was 84%. The majority (54%; N = 211) had been practicing as hospitalists for at least 3 years. Most reported that the pediatric inpatient unit (94%) and inpatient consultation service (51%) were a part of their regular clinical assignment. Most did not provide service in the normal newborn nursery (58%), subspecialty inpatient service (52%), transports (85%), outpatient clinics (66%), or as part of an emergency response team (53%). Many participated in quality improvement (QI) initiatives (84%) and practice guideline development (81%).

CONCLUSIONS

This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. However, the field is currently a moving target; there is significant flux in the hospitalist workforce and variation in the roles of these professionals in their clinical and nonclinical work environment.

Pediatric hospitalists and primary care providers: a communication needs assessment

BACKGROUND/OBJECTIVE

Existing research on hospitalist-primary care provider (PCP) communication focuses mainly on adult hospitalist models with little known about the quality of current pediatric hospitalist-PCP communication. Our objective was to perform a needs assessment by exploring important issues around communication between pediatric hospitalists and PCPs.

METHODS

Six previously identified issues around hospitalist-PCP communication from the adult hospitalist literature were abstracted and incorporated into an open-ended and closed-ended questionnaire. The questionnaire was pretested, revised, and administered by phone to 10 pediatric hospitalists and 12 pediatric PCPs residing in our 5-state catchment area. Interviews were transcribed and openly coded, and themes compared using qualitative methods.

RESULTS

The 6 identified issues were: quality of communication, barriers to communication, methods of information sharing, key data element requirements, critical timing, and perceived benefits. Hospitalists and PCPs rated overall quality of communication from "poor" to "very good." Both groups acknowledge that significant barriers to optimal communication currently exist, yet the barriers differ for each group. Hospitalists and PCPs agree on what information is important to transmit (diagnoses, medications, follow-up needs, and pending laboratory test results) and critical times for communication during the hospitalization (at discharge, admission, and during major clinical changes). Both groups also agree that optimal communication could improve many aspects of patient care.

CONCLUSIONS

Identifying and addressing barriers to these 6 issues may help both hospitalists and PCPs implement targeted interventions aimed at improving communication. Future studies will need to demonstrate the link between improved hospitalist-PCP communication and improved patient care and outcomes.

Achieving hospital medicine's promise through internal medicine residency redesign

The promise of the hospital medicine movement is that the hospitalist model of care will provide better outcomes than the system it replaced. This means improving the quality and processes of care, reducing inefficiencies and lowering costs. Despite some documented improvements in these areas hospitalists have yet to achieve their pinnacle. These shortfalls likely result from training providers in residencies that have yet to evolve to address the specific needs of hospitalists. While most internal medicine residency training programs stress inpatient care they underemphasize key components of a successful hospitalist career. This paper overviews the state of the hospitalist movement, the current educational training deficiencies and the methods to deliver hospitalist-focused training.

Just because you can, doesn't mean that you should: A call for the rational application of hospitalist comanagement

Medical comanagement has become a mainstay of hospital medicine. Several studies, however, suggest that medical consultation and comanagement may not be as effective as originally anticipated. The expansion of comanagement services has helped fuel massive demand for hospitalists and with it a critical and potentially destabilizing hospitalist manpower shortage. Comanagement may also drive unanticipated consequences such as facilitating surgeon and specialist disengagement and hospitalist career dissatisfaction and burnout. Comanagement services should be developed carefully and methodically, paying close attention to consequences, intended and unintended.

Where should hospitalists sit within the academic medical center?

One of the most significant changes in US hospitals over the past decade has been the emergence of hospitalists as key providers of inpatient care. The number of hospitalists in both community and teaching hospitals is growing rapidly, and as the field burgeons, many are questioning where hospitalists should reside within the academic medical center (AMC). Should they be a distinct division or department, or should they be incorporated into existing divisions? We describe hospital medicine's current trajectory and provide recommendations for hospital medicine's place in the AMC. Local social and economic factors are most likely to determine whether hospital medicine programs will become independent divisions at most AMCs. We believe that in many large AMCs, separate divisions of hospital medicine are less likely to form soon, and in our opinion should not form until they are able to fulfill the tripartite mission traditionally carried out by independent specialist divisions. At community hospitals and less research-oriented AMCs, hospital medicine programs may soon be ready to become separate divisions.

Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs

Categorical internal medicine (IM) residency training has historically effectively prepared graduates to manage the medical needs of acutely ill adults. The development of the field of hospital medicine, however, has resulted in hospitalists filling clinical niches that have been traditionally ignored or underemphasized in categorical IM training. Furthermore, hospitalists are increasingly leading inpatient safety, quality and efficiency initiatives that require understanding of hospital systems, multidisciplinary care and inpatient quality assessment and performance improvement. Taken in this context, many graduating IM residents are under-prepared to practice as effective hospitalists. In this paper, we outline the rationale for targeted training in hospital medicine and discuss the content and methods for delivering this training.

Spreading the word, not the infection: reaching hospitalists about the prevention of antimicrobial resistance

BACKGROUND

To reach and engage hospitalists in the prevention of antimicrobial resistance, the Society of Hospital Medicine and the Centers for Disease Control and Prevention developed and conducted a quality improvement workshop based on the Centers for Disease Control and Prevention's Campaign to Prevent Antimicrobial Resistance in Healthcare Settings.

METHODS

We aimed to examine motivating factors, perceived barriers, and cues to action for hospitalists to learn about and engage in the prevention of antimicrobial resistance and to determine whether a workshop can facilitate the implementation of a quality improvement project. Using the Health Belief Model as a theoretical framework, we interviewed hospitalists who attended (attendees) and did not attend (nonattendees) the workshop. Data were qualitatively coded and analyzed.

RESULTS

Nine attendees and 10 nonattendees participated in interviews. Motivating factors for attending the workshop included an interest in the topic of quality improvement and antimicrobial resistance prevention, the promotion of the workshop by institutions and colleagues, the opportunity to network with colleagues, and the qualifications of the presenter. Barriers to involvement in quality improvement efforts and the prevention of antimicrobial resistance for both attendees and nonattendees included perceived lack of time, other institutional priorities, and lack of administrative and institutional support. Attendees and nonattendees also identified perceived effective and preferred methods for receiving information about antimicrobial resistance, such as workshops and presentations, e-mail, institutional involvement, and the Internet. Overall, attendees thought that the workshop could be effective in facilitating the implementation of a quality improvement project.

CONCLUSION

By considering factors that influence behavioral change, interventions, such as the Society of Hospital Medicine workshop, have the ability to reach and engage clinicians such as hospitalists in quality improvement efforts to prevent antimicrobial resistance and improve adherence to infection control strategies. Furthermore, this study demonstrated that the Health Belief Model can provide an applicable framework for examining factors that influence clinician behavior.

Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting

BACKGROUND

Shortcomings in the quality of care of hospitalized patients at the end of life are well documented. Although hospitalists and residents are often involved in the care of hospitalized patients with terminal illness, little is known about their knowledge and beliefs concerning terminal illness, despite the importance of such physicians to the quality of care at the end of life.

DESIGN

In 2006 we conducted an exploratory study at a large academic medical center to examine the knowledge, attitudes, and practices of hospitalists and residents (n = 52, response rate = 85.2%) about the care of terminally ill patients. Data were collected using a 22-item survey instrument adapted from previously published instruments.

RESULTS

Several common myths about treating terminally ill patients were identified. These myths pertained to essential aspects of end-of-life care including pain and symptom control, indications for various medications, and eligibility for hospice. Physicians reported positive attitudes about hospice care as well as the belief that many patients who would benefit from hospice do not receive hospice at all or only late in the course of their illness.

CONCLUSIONS

Our findings identified misunderstandings that hospitalists and residents commonly have, including about facts essential to know in order to provide appropriate pain and symptom management. Future interventions to improve knowledge need to focus on specific clinical knowledge about opioid therapy, as well as information about eligibility rules for hospice.

Impact of Society of Hospital Medicine workshops on hospitalists' knowledge and perceptions of health care-associated infections and antimicrobial resistance

BACKGROUND

Health care-associated infections and antimicrobial resistance threaten the safety of hospitalized patients. New prevention strategies are necessary to address these problems. In response, the Society of Hospital Medicine (SHM) in collaboration with the Centers for Disease Control and Prevention developed and conducted workshops to educate hospitalists about conducting quality improvement programs to address antimicrobial resistance and health care-associated infections in hospitalized patients.

METHODS

SHM collected and analyzed data from pretests and posttests administered to physicians who attended SHM workshops in 2005 in 1 of 3 major cities: Denver, Colorado; Boston, Massachusetts; or Portland, Oregon.

RESULTS

A total of 69 SHM members attended the workshops, and 50 completed both a pretest and a posttest. Scores on the knowledge-based questions increased significantly from pretest to posttest (x = 48% vs. 63%, P < .0001); however, perceptions of the problem of antimicrobial resistance did not change. Most participants (85%) rated the quality of the workshop as "very good" or "excellent" and rated the workshop sessions as "useful" (x = 3.9 on a 5.0 scale).

CONCLUSIONS

Hospitalists who attended the SHM workshop increased their knowledge of health care-associated infections, antimicrobial resistance, and quality improvement programs related to these issues. Similar workshops should be considered in efforts to prevent health care-associated infections and antimicrobial resistance.

Discussing resuscitation preferences with patients: challenges and rewards

Discussing preferences regarding resuscitation is a challenging and important task for any physician. Understanding patients' wishes at the end of life allows physicians to provide the type of care patients want, to avoid unwanted interventions, and to promote patient autonomy and dignity. Hospitalists face an even greater challenge because they are often meeting a patient for the first time in a crisis situation. Despite the frequency with which clinicians have these conversations, they typically fall short when discussing code status with patients. In this evidence-based review, we discuss physician barriers to conducting effective discussions, offer a variety of approaches to enhancing these conversations, and review important communication techniques.