Yes, at least at Johns Hopkins Bayview. Doctors there reported their experience recently in the Annals of Internal Medicine. ER wait times were shortened and everyone seemed happy. Bob Wachter, although circumspect (not every program should tackle this, he said) had a generally positive reaction:
The American Hospital Association just released its 2008 estimates, and the number of hospitalists is now pegged at 27,000, which makes the field larger than cardiology or emergency medicine – the largest non-primary care field in Internal Medicine, and the fastest growing field in the history of medicine. This is staggering (next time, please remind me to trademark a term when I coin it), and owes to the fact that when most docs are running in the other direction, hospitalists step up to the plate and fix problems that need fixin’.
So a shout out to Eric Howell and the Hopkins Bayview crew for adding one more arrow to the hospitalist Quiver of Indispensability.
According to a conversation between Bob and the leaders at Bayview hospitalists were considered dispensable before the start of the bed control initiative. Now they’re considered indispensable.
This system is working well at Hopkins Bayview and might be a good fit at a few other hospitals, but it represents another step in the wrong direction for the hospitalist movement in general. When I made the move from traditional internist to hospitalist in 1999 hospitalists were considered clinicians (usually internal medicine trained) who, because they spent all or nearly all their professional time caring for inpatients, could ascend to extraordinary heights on the learning curve of inpatient medicine. The special expertise thus provided, along with the flexibility it afforded primary care physicians who chose not to round in hospitals, was the basis for their value. Over time things changed as leaders in the field thought up increasingly diverse tasks (clinical, procedural and administrative) to add to the hospitalist’s repertoire. Increasingly the specialty of hospital medicine is being viewed as a cadre of providers whose primary role is to offer business and administrative solutions to hospitals, with clinical expertise diminishing in importance.
There is little or no evidence to back up my opinions as to what’s “right” or “wrong” for the hospitalist movement. This developing model of hospitalist as jack of all trades might appeal to short timers looking for a good paying job while they decide what they really want to do, or until they land a fellowship. But I would wager that it is not what most of us looking for hospital medicine as a rewarding clinical career signed up for.
Related:
Hospital medicine: A mile wide and an inch deep?
More on SHM and hospitalist career satisfaction.
This paper, which could have come straight out of the Quackademic Medicine playbook, tells how it was done at two institutions in Canada. To successfully integrate woo into an academic medical center you need a promoter and a Trojan horse.
The promoter, aka the champion:
Our results suggest that a highly respected champion is necessary for the development of a new integrative medicine program. Both these programs were highly dependent on the efforts of champions with visions who were able to mobilize a wide range of individuals at many different levels within the health care system in order to facilitate the actualization of these integrative medicine programs..... What is most important is that the champion has credibility within the host institution, as well as with patients and clinicians who will work together in the integrative medicine program.
The Trojan horse (italics mine):
CARE began with only a consult service and to date does not include a chiropractor among the team members despite the high use of chiropractic among children. Similarly, the chiropractors in the SMH clinic began by explicitly limiting their legally-defined wide scope of practice to musculoskeletal conditions. However, as referrals and comfort levels increased over time, the SMH chiropractors have seen a wider range of referrals and increasingly have been asked to provide 'second opinion' level service when their physicians are unsure of the diagnosis (ie, because of diagnostic uncertainty, they will defer the diagnostic opinion to the chiropractors). This suggests an evolution in the physicians' level of trust and confidence towards the chiropractors. In both settings, the CAM providers were being integrated into conventional medicine contexts and as such, there was a degree of conventional medicine dominance created by the existing structures as has been described previously. In both clinics, the CAM providers were required to initially limit the scope of their activities in order to gain access to the integrative setting.
“Trojan horse” is a figure of speech I borrowed from Orac, who invoked the concept about a year ago to describe how pseudoscience gets its foot in the door of the academic medical center:
In reality, what bothers me about the whole concept of CAM is that it's basically a Trojan horse through which some therapies that might be evidence-based and could easily be integrated into our standard armamentarium of medical therapies are the "foot in the door" behind which hardcore woo lumped together as CAM follow, woo such as homeopathy, craniosacral therapy, reiki, and even reflexology, all of which I have encountered on wepages for academic centers devoted to CAM.
---it’s a rare and beautiful thing. Most journals are too PC to tackle it, choosing to be neutral or, in many cases promotional. So here’s a tip of the RW hat to the “Green Journal” for their recent review of acupuncture, concluding with:
So, after 3 decades of intensive research, is the end of acupuncture nigh? Given its many supporters, acupuncture is bound to survive the current wave of negative evidence, as it has survived previous threats. What has changed, however, is that, for the first time in its long history, acupuncture has been submitted to rigorous science—and conclusively failed the test.
The in vitro response to glucocorticoids is reduced in peripheral blood monocytes and BAL cells in obese as opposed to lean asthmatics. TNF expression was also increased in obese patients. Via American Journal of Respiratory and Critical Care Medicine.
The findings help explain link between obesity and asthma.
We’re all too familiar with the stress of transitioning from paper to the electronic medical record. It may work the other way around. What if you relocate form an area of high information technology to one of lower technology? Here’s what Vanderbilt researchers found:
After controlling for confounding effects, the authors found that graduates who transitioned to lower-HIT institutions reported feeling less able to practice safe patient care (P = .02), to utilize evidence at the point of care (P = .05), to work efficiently (P < .001), to share and communicate information (P = .03), and to work effectively within the local system (P = .007).
It’s not just Pub Med. Here’s a repository from Student BMJ, along with a list of free journal collections and searching tips.
The Cleveland Clinic Journal of Medicine has a very helpful update in
its December issue.Points of interest:
The efficacy of last year’s vaccine was unusually low at 40%. This year’s vaccine is expected to perform better.
Although oseltamivir (Tamiflu) is still recommended, last season saw a concerning rise in resistance. Virtually no resistance has been seen with zanamivir (Relenza).
Forget amantadine (Symmetrel) or rimantadine (Flumadine). Resistance is way too high.
The predictive value of clinical assessment of patients is poor. Use point of care testing.
The author states: Health care providers should offer vaccination at every opportunity between October and May. This means going beyond the core performance measures for hospitalized patients.
There is now a vaccine against H5N1 (bird flu).
CDC recommendations regarding influenza are here.
Wikipedia has some nice images and graphics.
Wernicke encephalopathy an internist's (and hospitalist's) dream, as treatment is easy and gratifying, while consequences of non-treatment are grave. Although usually discussed in the context of alcoholism, it can occur in a variety of settings of nutritional depletion. Examples reported in the literature include hyperemesis gravidarum and administration of TPN without thiamine supplementation. Nowadays it is increasingly seen following bariatric surgery. It usually occurs in the first month post operatively in the setting of protracted vomiting. The topic is reviewed in the Annals of Surgery, accessible via Medscape.
Chris Rangel wrote a provocative post about Joint Commission’s new disruptive behavior policy set to go into effect in 2009. He’s concerned that the definition of disruptive behavior (for which the JC recommends a zero tolerance policy) is a little vague, particularly this language (italics mine):
Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.
He points out:
Wait a minute! What this second part means is that basically, if you are having a bad day, then you’re a disruptive physician. If you have a bad bedside manner or you are not chummy with the hospital staff then you are disruptive. If you are distracted by a personal or professional crisis, then you are being disruptive. As one AMA delegate put it, if you are perceived as being disruptive to any particular staff member then you ARE disruptive.
By this definition a hospital administration could invoke the disruptive behavior policy to sanction anyone they don’t happen to like.
He goes on to point out an important unintended consequence of such a policy, which is to suppress strong opinions and concerns about hospital operations which may impact patient care. As I first noted here, such whistle blowing on the part of physicians, even legitimate expressions of concern, may be construed as disruptive.
He concludes:
The JC shouldn’t be trying to codify specific behaviors. Each case is unique and should be decided without specific description of behaviors leading to unfair bias while loosing sight of the endpoint of this whole endeavor. Neither should we expect every person in a high stress job where people’s lives are on the line to walk around like a smiling jackass in some hall monitor’s idea of the perfect Stepford Wives-like medical nightmare where everyone is pleasant and totally incompetent. Given the choice, I’d rather be treated by the brilliant asshole* then Dr. Smiley Mannequin. So far the AMA has asked the JC to reconsider their proposal. Let’s hope that the JC grows some CS.
While I agree with Rangel for the most part he failed to mention that the new JC policy is no respecter of persons---it applies equally to nurses, pharmacists, doctors and administrators. There’s no double standard. Everyone in the health care environment is expected to be civil. It’s not just about doctors anymore. As I pointed out in a recent post Alan H. Rosenstein, MD, MBA, an expert who has written a great deal on this subject, said that many doctors are the recipients rather than the perpetrators of disruptive behavior. The Joint Commission, much to its credit, recognizes that fact. The Sentinel Event Alert regarding the new standard is careful to avoid the term “disruptive physician” and says:While most formal research centers on intimidating and disruptive behaviors among physicians and nurses, there is evidence that these behaviors occur among other health care professionals, such as pharmacists, therapists, and support staff, as well as among administrators.
The report recommends several actions including (italics mine):Educate all team members – both physicians and non-physician staff – on appropriate professional behavior defined by the organization’s code of conduct.
Hold all team members accountable for modeling desirable behaviors, and enforce the code consistently and equitably among all staff regardless of seniority or clinical discipline…
If you’ve worked in a hospital for any length of time you know that this disruptive behavior thing works both ways. That’s why I’m more than a little disappointed in the New York Times distortion of the issue in their recent article Arrogant, Abusive and Disruptive — and a Doctor. It’s a one sided portrayal of the stereotypical instrument throwing physician who intimidates everyone else on the health care team:Still, every nurse has a story about obnoxious doctors. A few say they have ducked scalpels thrown across the operating room by angry surgeons. More frequently, though, they are belittled, insulted or yelled at — often in front of patients and other staff members — and made to feel like the bottom of the food chain. A third of the nurses in Dr. Rosenstein’s study were aware of a nurse who had left a hospital because of a disruptive physician.
With JC’s broad definition of disruptive behavior applied across the whole spectrum of health care providers the possibilities are endless. If a nurse grudgingly carries out a doctor’s orders, if an attending leans a little too heavily on a medical student or if administration is unreceptive to expressed concerns about patient care, one can invoke the disruptive behavior policy.
About the only thing informative about this report from the AAP is its documentation of the spread of woo like a cancer throughout academic and community medicine. Otherwise it’s pretty much a fluff piece, or so it seems to me.
Seems there’s never a copy around when I need one, so I’ll link it here.
You mean it won’t be smoke free anymore? Who knew?
Not much mainstream coverage about this, but some bloggers have weighed in.
Dr. Wes
Happy Hospitalist
BOSO
I mean, it’s all about leading by example for the public good, right?
This was a high risk population of hypertensives. The study was published in NEJM. Despite nearly identical BP control, outcomes were better in the Lotrel group:
There were 552 primary-outcome events in the benazepril–amlodipine group (9.6% and 679 in the benazepril–hydrochlorothiazide group (11.8%), representing an absolute risk reduction with benazepril–amlodipine therapy of 2.2% and a relative risk reduction of 19.6% (hazard ratio, 0.80, 95% confidence interval [CI], 0.72 to 0.90; P<0.001).
In a Medscape piece concerning the study Dr Franz Messerli commented:
"This landmark study unequivocally relegates hydrochlorothiazide from first-line to third-line therapy at least in a patient population with similar demographic and clinical features as in ACCOMPLISH," said Messerli. "The issue is not to be taken lightly, since hydrochlorothiazide remains one of the most commonly prescribed antihypertensive drugs….”
---is reviewed in NEJM. Very comprehensive and helpful.
---if someone would tell me what it is.
Bob Wachter describes a wonderful clinical service at UCSF---one that is well organized, delivers excellent care and is rated highly by patients, families and house staff. He calls it the palliative care service but doesn’t quite define what it is, leaving me wondering about the whole concept. Think I’m nit picking? Try asking your colleagues, or searching the literature on what palliative care really is. Good luck in getting a coherent answer.
Even the usually straightforward Wikpedia is vague, describing palliative care as something which is delivered in the context of both curative care and hospice care. So what is it, exactly?
Bob’s post is not explicit but from his title (My Patients Are Dying… And I’ve Never Been Prouder) he’s talking about end of life care. But Mount Sinai School of Medicine Professor R. Sean Morrison, MD, who has written a great deal about palliative care, said in a recent Medscape video editorial that “Unlike hospice, hospital palliative care is not dependent on prognosis.” Moreover, in an earlier NEJM article Morrison’s description of palliative care does not preclude curative care as implied by this statement: “Palliative care should be offered simultaneously with all other medical treatment.” In this recently published study the majority of patients on palliative care services were discharged alive. So, again, what is it?
The closest thing you’ll find to a definition (and it’s not really satisfactory) is something like the one in the NEJM article:
Palliative care aims to relieve suffering and improve the quality of life for patients with advanced illnesses and their families through specific knowledge and skills, including communication with patients and family members; management of pain and other symptoms; psychosocial, spiritual, and bereavement support; and coordination of an array of medical and social services.
OK. Palliation means making the patient’s illness get better while paying attention to the surrounding psycho-social and spiritual issues. It’s what we should be doing for all our patients all the time, so why does a hospital need a special service? (The focus on patients with advanced illness doesn’t really narrow things down much; most hospitalized patients have advanced illness). My reading suggests that palliative care is simply hospital medicine raised to a higher level of excellence, efficiency, organization and patient centeredness. It sounds a lot like what the Institute of Medicine has been harping at all of us to do. The idea of a palliative care “program” suggests a separate team to deliver this excellent care while the rest of us settle for mediocrity! Palliative care claims to have distinctive attributes, but they really shouldn’t be distinctive. They should be the norm.
A common thread in many descriptions of palliative care relates to the quality of communication. Discussions go beyond DNR status and whether the patient has a living will to the education of patients and families on the big picture of the patient’s health and realistic expectations concerning the limitations of treatment. This leads to greater patient satisfaction, more informed and rational decision making, and often the avoidance of ICU care, feeding tubes and other technologies which, in many patients, serve only to decrease quality of life. While these interventions are ineffective in many patients they are costly, which is probably why palliative care programs save hospitals money. Lots of money. But again, why should good communication with patients and families require a special care service?
Like so many other concepts in medicine, the word “palliative” has been hijacked. The idea of palliative care has been administratively defined by people with agendas. For clinicians it’s been an exercise in obfuscation.
The excellence and the efficiency of what is called palliative care is something to get excited about. It’s something we should all strive for. I would like to see our hospitalist program spearhead a multidisciplinary effort to take these ideas to a new level of excellence for all of patient care. But I don’t think I’d call it palliative care. I’d call it something else. I’m not sure what, but something with more meaning.
Some guidelines are finally out, issued by the American College of Physicians. Medscape provides a summary here. Among the recommendations:Recommendation 1 (Disclosure): When clinicians prescribe methadone, they should inform patients about arrhythmia risk.
Recommendation 2 (Clinical History): Clinicians should ask patients about any history of structural heart disease, arrhythmia, or syncope.
Recommendation 3 (Screening): All patients should have a pretreatment electrocardiogram (ECG) to measure QTc interval and a follow-up ECG within 30 days and each year.
I wonder how many people are actually doing this. I started harping about it way back here.
A slide presentation is presented here via Clinical Cases and Images blog.
Also check out these resources.
Here’s one of my old posts on Google vs PubMed.
American Family Physician has a review and some recommendations. Unfortunately the journal is no longer open access so I can’t link to the article (not even the abstract). But here’s a Medscape CME piece which summarizes the review. (Fair and balanced? Yes, as far as I can tell, and no industry support!).This issue has garnered increasing recent attention in hospital medicine. The new emphasis is on lowering the threshold for detecting renal injury. Changes in serum creatinine formerly considered modest should prompt a review of medications and a search for means to mitigate renal damage.
This may be the biggest study yet, from St. Luke’s, Kansas City, MO.
Conclusion In this large single-institution study, rapid response team implementation was not associated with reductions in hospital-wide code rates or mortality.
