How a Cup of Coffee Can Curb Costs in Hospitals and Improve Patient Safety

19 04 2010

Recently, I was fortunate to be an invited guest at the 1st annual George Washington University Graduate Medical Education retreat.  I was especially intrigued by a breakout session on how to deal with the disruptive resident or attending, a topic that was the theme of my own institution’s GME retreat earlier this year.  I observed a terrific role play by a psychiatrist Charles Samenow, who played the on-call medicine resident, and gynecologist and Associate Dean for Graduate Medical Education Nancy Gaba, who played the role of a medical student who was asked to call the medical resident.  I looked on as the resident mistreated a student was told to page the resident to admit a patient from the ER to the medical floor by cutting her off and berating her for calling him before she had seen the patient.  Later, one of the audience members was asked to role play how to handle providing feedback to this resident.  She demonstrated the ‘bulldozer’ approach of taking the issue head on while the resident tried every trick in the book to avoid the issue at hand (redirect conversation, blame others, etc.).   

While this was all make believe, unfortunately, disruptive behavior  in the medical workplace is a real problem.  And, the most common offenders are physicians.  Behaviors could range from the egregious (harassment, verbal or physical abuse, lying, intimidation) to not complying with hospital standards (failing to do dictations for example).  Disruptive behavior, especially intimidation, is also a patient safety issue since no one feels like going up against a bully.  As a result, the Joint Commission has stepped in, mandating that hospitals have a process to deal with these disruptive docs and raise awareness about unprofessional behavior in the medical workplace. 

Fortunately, a team from Vanderbilt led by Dr. Gerald Hickson, has developed a program to remediate disruptive physicians called Patient Advocacy Reporting System (PARS®).  The main premise of the program is to take unsolicited patient complaint and look for outliers – these outliers are the bad eggs that are responsible for more than their share of malpractice lawsuits and cost the hospital money down the road.  The first intervention is a ‘cup of coffee’ conversation with a trusted peer.  This peer will review a standard report that shows the doc is an outlier.  Apparently, the cup of coffee works!  Most docs respond to this intervention and don’t show up on the outlier list again. However, a small fraction of docs fail this intervention and need more intense remediation or even are let go due to their pattern of unprofessional behavior.   Over 30 hospitals, including our own, have signed on to this program, in large part because they can show that this process reduces malpractice costs.  As a result, Dr. Hickson’s team has even shown that some doctors who were let go at one institution ‘reappear’ on the grid at another institution in their data.  Scary huh?

So far, the PARS® program only deals with data from patients.  This may miss some of the disruptive docs who have a terrific bedside manner, but still berate others in the healthcare workplace, like nurses or medical students.  That is why many programs are now looking to augment reporting by these groups.  For example, the Liaison Committee on Medical Education, which accredits medical schools, is very concerned with the roughly 15 to 20% of graduating students that report mistreatment in the medical workplace.  They now require that medical schools develop policies and procedures for students to promptly report mistreatment without fear of retaliation and also educate faculty about student mistreatment.  As a result, our medical school has appointed Ombudsmen who discretely investigate student complaints of mistreatment and serve as student advocates in these instances.

However, asking students whether they were mistreated is sometimes very complicated due to differing perceptions of what is appropriate in the context of patient care.  For instance, a physician may shout at a medical student to move out of the way during a cardiac arrest or emergent patient situation to ensure that the patient receives urgent attention.  There’s always confusion about whether asking a student to get coffee for the team is mistreatment.  As a result, my colleague, Dr. Shalini Reddy and I have developed the following guide to help explain to students what mistreatment is (Student Guide to MISTREATment).   For any educators out there, there are also plenty of video examples from our favorite medical TV shows to raise awareness of the issue. 

So the next time you are asked to get a cup of coffee by a trusted friend, it’s also a good time to think about your behavior.

Vineet Arora, MD

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Hospitalist Haters: Can We Bury the Hatchet?

15 04 2010

Yes, it is true they are still out there.  They believe that students and residents are choosing hospital medicine over primary care so hospitalists are to be blamed for the primary care shortage.  They also believe that the rise of hospital medicine has made primary care less attractive.  Then, there is the salient argument that care transitions are more inherent and vulnerable due to hospitalists.   Of course this hatred is not new.  As a resident, I remember watching Larry Wellikson, CEO of the Society of Hospital Medicine, back in 2002 publicly berated by some very smart people at a conference calling the organization a “SHaM.”  Ironically, this was a conference on how to ‘Revitalize Internal Medicine.’  Given the dramatic rise of hospital medicine since then, it is still surprising when the hatred reemerges in the public domain. It appeared in a recent issue of the Annals of Internal Medicine.  I just returned from the Society of Hospital Medicine conference, and learned there are now 30,000 hospitalists.  Hospitalists are here to stay – so what to do?  Well, let’s explore these myths one by one.

Is the declining interest in primary care due to hospital medicine? While I am very concerned about the lack of interest in primary care, the answer to this question is no.  If hospitalists did not exist, there would still be declining interest in primary care among medical students and residents.  The decline in entry into primary care among medical residents is largely explained by the rising interest in subspecialty medicine, in which 2/3 of internal medicine residency graduates intend to enter.  This choice is largely driven by the financial disparity between high paying subspecialties and you guessed it, primary care physicians.  In fact, hospitalists are losing candidates left and right to subspecialty fellowships also!  As a result, most residents are not deciding between hospitalist and primary care- but between one of them and pursuing a fellowship.  Is it all financial?  Well, I personally believe that residents are also uncomfortable with knowing ‘a little about a lot’ and desire a focused area of practice in the ever expanding domain of medical knowledge.  And, who could blame them?  As a hospitalist, I feel that way often- this is something we need to prepare our residency graduates for – caring for the undifferentiated patient – whether it be in the outpatient or inpatient settings.

It is important to note that the primary care problem starts much earlier than residency!  A widely cited report shows that only 2% of graduates are interested in entering general internal medicine, and less than 20% overall in primary care fields.  The biggest competition is the “ROAD” - Radiology Ophthalmology Anesthesiology or Dermatology – or any other competitive specialty that is lifestyle oriented – meaning high pay with controllable hours.  For any nonmedical person in the world, who would not pick the high paying job with controllable hours?  This is why we need to reduce the disparity between physician specialties in the US and ensure that both primary care and hospital medicine are seen as viable and yes, glamorous careers. 

Has hospital medicine made primary care less attractive? For the sake of argument, let’s imagine the answer is yes – what would that mean? It would mean that a busy primary care physician would desire to go to the hospital to follow their patients early in the morning before clinic and after clinic to round.  They would constantly get pages from the nurses during the day even though they were off premises.  The hospital would require that the primary care physician participate in the latest quality improvement project to improve CMS metrics.  While this may still be possible in more rural areas with less acute patients, the reality is that hospitalized patients today are sicker than ever before.  Hospitals and frankly the government are demanding that physicians are in house to help meet their quality metrics improve patient safety as opposed to rounding on an as needed basis.

 A new analysis shows that the probability of hospitalization for a patient who was cared for by a primary care physician fell before the hospitalist movement started.  Hospitalists emerged as a way to make it easier for primary care physicians to work in the office and not go through the trouble of going on rounds.  So in other words, hospitalists appear to be helping primary care physicians since not many of their patients are in the hospital.  Not surprisingly, a survey demonstrated that 2/3 of primary care physicians thought hospitalists were in fact a good idea.

Do patients prefer seeing their own doctor in the hospital? This question was recently put forth by GlassHospital.  While they may long for the early days of that type of continuity, most patients and their families want to see a doctor immediately when their family member is sick.  Poignant stories from patient safety advocates (Sorrel King, Helen Haskell and others) highlight the need for emergent evaluation by a physician when their loved one is ill.  They can’t wait until clinic ends.  Care by hospitalist is also cheaper and associated with better outcomes, certainly something desirable in healthcare.  Lastly, there is some data from our group that suggests that roughly 1/4 of patients prefer their PCP to see them in the hospital, 1/4 prefer their hospital doctor, and the remaining have no preference.  Patients are also not willing to pay for their primary care physician to see them.   

Are hospitalists responsible for suboptimal care transitions? Well, this is the great sticking point for hospital medicine.  In that same survey where 2/3 of PCPs liked hospitalists, only 1/3 felt they received timely communication about a patients discharge.  A recent review in JAMA supports this assertion. Since that time, however, hospitalists have realized this problem and have adopted care transitions as part of their core mission.  Care transitions are a core competency of hospital medicine.  With funding from the Hartford Foundation, the Society of Hospital Medicine has launched Project BOOST – Better Outcomes for Older Adults Safe Transitions which has been implemented nationwide and in a consortium of hospitals in Michigan and is about to go live in California.  So, while this is the one area that continues to be “unfinished business” in hospital medicine, it is also the area where the greatest progress and improvements for patient safety are being made.

So, can hospitalist haters bury the hatchet?

I hope so.  After all, hospitalists need primary care physicians.  This year, when I’ve been on service, I’ve noted that a primary care physician who accepts new patients is an endangered species.  As a result, I have begged some of my colleagues or other members in the community to follow some of these complex patients.  Since the patients have to leave the hospital when they are medically clear even if their follow-up is spotty, I continue to sign home health orders, receive pages from patients to field their questions, and field questions from subspecialists who are seeing the patient in follow up.  As a result, I have a handful of patients who actually identify me as their physician when they go to an ER in our community.  While I am suddenly reminded of the great pride it is to be known as someone’s doctor, I know that what we all really need is a good primary care physician.

Vineet Arora, MD

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Lost in Translation..but the Familiar Language of Medical Education

7 04 2010

Grey’s Anatomy, Scut Work, Burnout, & Rural Shortages in China too…

My husband and I recently traveled to Wuhan Medical School in the Hubei Province in central China.  Our medical school has partnered with Wuhan to help inform their curricular reform efforts.  We spent 4 days touring the hospitals and teaching facilities, meeting students and faculty, going on rounds, and giving talks.  Although the language barrier was challenging, we had incredible translators who worked to translate every slide we spoke into Chinese.  We also had the opportunity to observe and talk to students, residents, and faculty through translators to better understand their experiences. 

Preclinical Student Education  Interestingly, the preclinical students told me they watch Grey’s Anatomy and House and wonder if that is what medicine is like.  I told them that US medical students and premeds have wondered that too!  And just like our preclinical students, these students are very excited to get to the wards and desire earlier exposure to patient care.  Fortunately, Wuhan has already started instituting reforms for a pilot group of preclinical students through a more integrated block style curriculum that focuses on incorporating clinical medicine into the preclinical teaching.   They also have state of the art simulation to help students practice clinical medicine.  As one attending said, “the book is book, but practice is practice.”

One big difference is that Chinese medical students are a lot younger – starting right after high school and have little understanding about a medical career.  A standardized national exam in high school dictates whether students will get to go to medical school.  The default pathway for students that don’t get into medical school is often nursing school.  Therefore, many of the nursing students are disengaged.  Once in medical school, the standard pathway is the 5 year option, with smaller 7 and 8 year options for select few who desire more clinical training and research.   Wuhan also has a foreign medical student population that include students from India, Canada, Africa and even the U.S. who spend 4 hours a day studying Chinese on top of their preclinical studies so they can eventually interact with Chinese patients.  And yes, they don’t have Facebook or Twitter and use Baidu instead of Google. 

Rounds and Clinical Rotations Probably the most fascinating part of our trip was observing teaching rounds in 2 Chinese hospitals.  The patients were three to a room and were wearing their own clothes instead of gowns.  It is cold in the hospital since the buildings are not heated (I was wearing my winter coat the whole time).   In both hospitals we were in, the clinical students did not ‘follow’ patients but worked as a group (4 to 5) with one attending physician to see all the patients. 

Through the long streams of Chinese, we could make out the terms “COPD” in a lung ward or “Framingham” when observing a cardiologist teaching medical students.  Students who were thirsty for clinical teaching were furiously taking notes in little books.  The familiar tradition of the attending ‘pimping’ the students was also observed.  Students did not ask a lot of questions, which is consistent with more of the passive learning style documented in Chinese medical education –one thing that Wuhan very much wants to reform.   Students were also carrying all the charts for the rounds and expected to do other clerical tasks. When I explained the term ‘scut work’ to our Chinese medical student translator, she told me that this work is actually part of their ‘cooperation score’ on the evaluation symbolizing teamwork.  

Residency and Clinical Practice There is currently no required residency training but formal residency training is on the verge of starting across China.  Currently, some graduating medical students will do an internship at the hospital underneath a senior doctor.  One of the interns we met with said that she lives at the hospital (in a dorm) working 6 days a week with one day off working roughly 70-80 hours per week taking overnight call once a week.  Since not every department has an intern every year, the attendings sometimes have to take call weekly too. As a result, the doctors we met with reported being fatigued and burned out and wondering how to balance work and life (sound familiar?).  And lastly, as described in several articles in this week’s issue of Academic Medicine in the US, there is also a major shortage of Chinese doctors in rural areas since everyone wants to live in urban areas.   

Even though we were there to teach, we ended up learning that we had a lot in common.   A special thank you to all of our hosts at Wuhan Medical School who went above and beyond to make us feel welcome!

Vineet Arora, MD

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