As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.

I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.

Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:

Healthcare Can’t Live without Us

Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.

We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.

We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.

We Now Own Some Very Tough Problems

Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.

Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.

We Are Shaping the Pipeline

Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.

It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.

We Have Incredible Leadership

I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.

We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.

SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.

We Are a Bargain

One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.

But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.

My Mission

So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.

Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.

Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to scheured@musc.edu.

As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.

I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.

Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:

Healthcare Can’t Live without Us

Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.

We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.

We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.

We Now Own Some Very Tough Problems

Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.

Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.

We Are Shaping the Pipeline

Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.

It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.

We Have Incredible Leadership

I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.

We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.

SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.

We Are a Bargain

One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.

But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.

My Mission

So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.

Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.

Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to scheured@musc.edu.

As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.

I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.

Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:

Healthcare Can’t Live without Us

Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.

We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.

We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.

We Now Own Some Very Tough Problems

Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.

Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.

We Are Shaping the Pipeline

Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.

It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.

We Have Incredible Leadership

I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.

We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.

SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.

We Are a Bargain

One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.

But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.

My Mission

So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.

Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.

Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to scheured@musc.edu.

My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:

• Why is my usual doctor (PCP) not going to be in charge of my hospital care?
• Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
• Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
• How will the hospitalist know my medical history, and will she communicate with my PCP?

Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.

Unintentional Undermining of Patient Confidence

Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.

To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.

Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.

Scripts for Nurses and Non-Hospitalist Physicians

Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.

Or:

Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.

The Two Most Valuable Things For A Patient To Hear Are...

1. That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
2. That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.

My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.

It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.

Ensure Others Know the Hospitalist’s Name

Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”

Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course

.

My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:

• Why is my usual doctor (PCP) not going to be in charge of my hospital care?
• Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
• Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
• How will the hospitalist know my medical history, and will she communicate with my PCP?

Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.

Unintentional Undermining of Patient Confidence

Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.

To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.

Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.

Scripts for Nurses and Non-Hospitalist Physicians

Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.

Or:

Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.

The Two Most Valuable Things For A Patient To Hear Are...

1. That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
2. That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.

My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.

It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.

Ensure Others Know the Hospitalist’s Name

Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”

Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course

.

My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:

• Why is my usual doctor (PCP) not going to be in charge of my hospital care?
• Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
• Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
• How will the hospitalist know my medical history, and will she communicate with my PCP?

Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.

Unintentional Undermining of Patient Confidence

Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.

To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.

Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.

Scripts for Nurses and Non-Hospitalist Physicians

Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.

Or:

Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.

The Two Most Valuable Things For A Patient To Hear Are...

1. That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
2. That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.

My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.

It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.

Ensure Others Know the Hospitalist’s Name

Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”

Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course

.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

HIV testing should become a part of routine care for adolescents and young adults.

Begin to offer testing to patients aged 13 years as part of regular well-visit exams. Testing all patients at the onset of adolescence helps establish that this is part of routine and universal health care for all of your patients. By testing everyone, we are trying to remove the stigma associated with HIV testing and the implication that certain individuals or members of a group are at "high risk" and, therefore, are the only ones who need to be tested.

Photo courtesy Dr. Tom Folks/NIAID-NIH

It’s probably a good idea to inform parents of your plan to routinely test their adolescent at this initial 13-year-old well-child visit. This helps establish the routine nature of the test and prepares them for repeat testing in years to come.

We do encounter hesitant parents. We get parents who say, "Doctor, my son or daughter is not at risk!" I’m happy to say to parents, "I’m sure that is true, but again, it’s very important for us to establish that this is a routine test, the same way we do routine testing for risk of anemia and risk of diabetes in teenagers." Again, emphasize that your approach is universal, so the parent understands that you are not singling out their adolescent for any reason.

Counseling the adolescent patient with regard to the risks of acquiring HIV infection is an important aspect of testing for HIV, but should never be a limitation to doing an HIV test. In other words, if you don’t have the time to counsel a patient as fully as you’d like, that doesn’t mean that you shouldn’t be testing that patient. Ideally, you will have the time to obtain a careful and thoughtful history with regard to risk behaviors. Also ask appropriate anticipatory guidance questions to help direct you in counseling your individual patient.

It is important to remember that even during the initial "adolescent visit" at 13 years, the adolescent should be granted confidentiality with regard to answering risk-behavior questions. I can almost guarantee you that a provider is not going to get a truthful answer from that adolescent regarding sex and drugs if they are being questioned in the presence of their parents.

A good approach to counseling is to start by asking very general questions. You can say, for instance, "I know many kids these days are having sexual contact that could put them at risk for sexually transmitted infections, including HIV infection. As far as you know, are any of your friends currently having sexual contact that would put them at that kind of risk?" Their answer will be yes, no, or maybe. Then your follow-up question is, "Of course, you know I’m interested in you as my patient. Are you currently having any kind of sexual contact that might put you at risk of HIV infection? By that I mean are you having oral sex, vaginal sex, or anal sex?" I think it’s important to be this specific because adolescents have some set attitudes as to what is and what is not "sexual contact" or "sexual activity," and these may not be the same as your or my ideas about these things. It is also good to know the nature of their actual behaviors, because some sexual behaviors increase the risk of HIV and STD infection.

This regular questioning needs to be supplemented by regular testing for HIV status. Even if you’ve cared for a patient since birth, there is very strong likelihood that – at least at some point during their teenage years – they may not be completely forthright about their behaviors (even without their parents in the room).

Our patients who are sexually active have come to understand that condom use is now the socially acceptable norm. Therefore, very few of them will report that they did not use condoms at their last intercourse. However, despite these universal claims, in our practice we still run an asymptomatic chlamydia rate of about 12% among young women and about 7% among young men. Obviously, someone is not using condoms at each and every sexual encounter.

One way to explain your testing strategy to a teenage patient is to say, "Today we’re going to do some tests. We are going to do a hemoglobin test and a hematocrit because you’re a young, menstruating female, and we know you’re at risk of anemia. We’re going to look at your kidney function and glucose, and make sure you’re not at risk of diabetes; and we’re going to do a routine HIV test because it’s part of the testing we do in all teenagers."

Every adolescent should know that they are being tested for HIV. We allow them to tell us "Gee, I’d rather not be tested." We hear that, but we hear it pretty rarely. I would say that fewer than 5% of kids opt out of an HIV test when the test is presented to them.

Key to this approach to routine testing is not having to offer extensive pretest preparation or written informed consent. A total of 40 states and the District of Columbia allow for facilitated testing that doesn’t require written, informed consent. Unfortunately, this also means that there are still a handful of states that do require prior written consent. So pediatricians need to know their state law. More information on testing in specific jurisdictions is available from the National HIV/AIDS Clinicians Consultation Center. Clearly, if you are in a state that requires informed consent, it adds a level of complexity to the testing process.

So how often should you test an adolescent? The Centers for Disease Control and Prevention recommends HIV testing for individuals of 13-64 years of age with some regularity and periodicity. There is some argument regarding the frequency of testing. If the pediatrician knows – either through questioning or even through suspicion – that the adolescent may be engaging in behaviors that might put her or him at risk of HIV infection, then that testing should be done annually. If you cannot ascertain an exact risk profile for an individual, decide what "reasonable periodicity" would be for you. My recommendation is to test at least every other year, and annually or more frequently in sexually active or drug-using adolescents.

Your patients and their families may ask you about HIV testing that is anonymous (that is, blinded testing in which no one except the patient knows who has been tested) vs. confidential (in which the identity of the patient tested is known to the tester). We prefer confidential testing because it allows us to link patients into care if and when they are identified as positive. For anonymous testing to work, you presume the adolescent is going to be mature enough to take action on the basis of a test result. That may be true, but the guidance of a thoughtful and compassionate health care provider to counsel an adolescent after a test result is invaluable.

Ideally, most pediatricians can perform rapid HIV testing. That is clearly the most efficient means because then patients have the results immediately. If you are not able to offer rapid testing and have to send blood out for a result, my feeling is that you should always communicate the results directly to an adolescent, as you would with any medical test. You can work out the best system of doing that for your practice. You could say something like, "Let me make sure I have your cell phone number so I have the best way to contact you. I would like to share your test results with you regardless of what they are."

If an initial blood test comes back positive, it can be anxiety provoking and clearly cause concerns on the part of the patient. Unfortunately, we cannot eliminate all of this anxiety. You can then contact the patient directly and say, "There is something about your testing we are going to need to repeat, so please make an appointment to come back in."

Dr. Lawrence D’Angelo is chief of the division of adolescent and young adult medicine at Children’s National Medical Center in Washington. He said he had no relevant financial disclosures.

If I decide that a patient does not meet the criteria for admission, who is then responsible for the discharge of that patient from the ED? The hospitalist usually dictates a consult and recommendation, and even sets up appropriate follow-up. However, since the patient was already given to me to admit, should ED docs discharge the patient or should I?

—Bharathi Upendran Thuraisamy, MD

Dr. Hospitalist responds:

This question is one that we confront frequently in our line of work. To me, there are three basic categories of admission:

1. The case that clearly needs admission. No need for extensive discussion there.
2. The case that can go home, but the ED is calling you just to “make sure” or ask for a quick piece of information. Now, this can get a bit tricky, but you should be able to judge it by the length of the phone call. Less than a minute? OK, sounds like you’re in agreement, and the ED doctor can take it from there.
3. The third category, which is described in your question, is when the ED says: “I have an admission for you,” and your reaction after hearing the presentation is, “Boy, that sure doesn’t sound like an admission to me.”

As a rule of thumb, if the ED physician describes it as an admission, then the onus will be on you to work up the patient and decide on the management plan. Generally, when the ED doctor thinks that a patient warrants admission, then, in their mind, the case then belongs to you, not them. This is consistent with the recent American College of Emergency Physicians’ position that ED doctors will no longer write admission orders.

At this point, if the ED doc thinks the patient needs to come in, then, as you describe, you’ll need to do an evaluation, dictate a consult, and decide on the disposition. Since the ED is technically an outpatient setting, you’ll need to bill your professional services accordingly, using CPT codes 99281-99288.

When it comes to the physical act of discharging a patient, I would use the discharge forms already present in your ED. In addition, I would make it a point to communicate directly with the nurse caring for the patient. My standard explanation would go something like this: “Dr. ED asked me to evaluate this patient. I saw them and told them that they could go home with appropriate follow-up. I’ve written/dictated a note and filled out the paperwork. Is there anything else that I need to do?”

More or less, I try to make it as easy for the nurse and the patient as possible. Please note that I did not include the ED doctor in that statement. It’s not that I don’t want you to be nice to them, but, depending on the physician, you can end up enabling their behavior, and pretty soon they’ll call you with every patient that might need admission. My favorite example was an older ED physician at a small community hospital who once called me to admit a patient. All he said was, “I’ve got a 67-year-old lady with abdominal pain.”

That’s it. He had not examined the patient, nor done any labs or studies. My mistake was just being available. Now, I know that’s what we do as hospitalists, but there’s a line between being helpful and getting worked over. So help when you can, and do it with a smile. But be firm.

If I decide that a patient does not meet the criteria for admission, who is then responsible for the discharge of that patient from the ED? The hospitalist usually dictates a consult and recommendation, and even sets up appropriate follow-up. However, since the patient was already given to me to admit, should ED docs discharge the patient or should I?

—Bharathi Upendran Thuraisamy, MD

Dr. Hospitalist responds:

This question is one that we confront frequently in our line of work. To me, there are three basic categories of admission:

1. The case that clearly needs admission. No need for extensive discussion there.
2. The case that can go home, but the ED is calling you just to “make sure” or ask for a quick piece of information. Now, this can get a bit tricky, but you should be able to judge it by the length of the phone call. Less than a minute? OK, sounds like you’re in agreement, and the ED doctor can take it from there.
3. The third category, which is described in your question, is when the ED says: “I have an admission for you,” and your reaction after hearing the presentation is, “Boy, that sure doesn’t sound like an admission to me.”

As a rule of thumb, if the ED physician describes it as an admission, then the onus will be on you to work up the patient and decide on the management plan. Generally, when the ED doctor thinks that a patient warrants admission, then, in their mind, the case then belongs to you, not them. This is consistent with the recent American College of Emergency Physicians’ position that ED doctors will no longer write admission orders.

At this point, if the ED doc thinks the patient needs to come in, then, as you describe, you’ll need to do an evaluation, dictate a consult, and decide on the disposition. Since the ED is technically an outpatient setting, you’ll need to bill your professional services accordingly, using CPT codes 99281-99288.

When it comes to the physical act of discharging a patient, I would use the discharge forms already present in your ED. In addition, I would make it a point to communicate directly with the nurse caring for the patient. My standard explanation would go something like this: “Dr. ED asked me to evaluate this patient. I saw them and told them that they could go home with appropriate follow-up. I’ve written/dictated a note and filled out the paperwork. Is there anything else that I need to do?”

More or less, I try to make it as easy for the nurse and the patient as possible. Please note that I did not include the ED doctor in that statement. It’s not that I don’t want you to be nice to them, but, depending on the physician, you can end up enabling their behavior, and pretty soon they’ll call you with every patient that might need admission. My favorite example was an older ED physician at a small community hospital who once called me to admit a patient. All he said was, “I’ve got a 67-year-old lady with abdominal pain.”

That’s it. He had not examined the patient, nor done any labs or studies. My mistake was just being available. Now, I know that’s what we do as hospitalists, but there’s a line between being helpful and getting worked over. So help when you can, and do it with a smile. But be firm.

If I decide that a patient does not meet the criteria for admission, who is then responsible for the discharge of that patient from the ED? The hospitalist usually dictates a consult and recommendation, and even sets up appropriate follow-up. However, since the patient was already given to me to admit, should ED docs discharge the patient or should I?

—Bharathi Upendran Thuraisamy, MD

Dr. Hospitalist responds:

This question is one that we confront frequently in our line of work. To me, there are three basic categories of admission:

1. The case that clearly needs admission. No need for extensive discussion there.
2. The case that can go home, but the ED is calling you just to “make sure” or ask for a quick piece of information. Now, this can get a bit tricky, but you should be able to judge it by the length of the phone call. Less than a minute? OK, sounds like you’re in agreement, and the ED doctor can take it from there.
3. The third category, which is described in your question, is when the ED says: “I have an admission for you,” and your reaction after hearing the presentation is, “Boy, that sure doesn’t sound like an admission to me.”

As a rule of thumb, if the ED physician describes it as an admission, then the onus will be on you to work up the patient and decide on the management plan. Generally, when the ED doctor thinks that a patient warrants admission, then, in their mind, the case then belongs to you, not them. This is consistent with the recent American College of Emergency Physicians’ position that ED doctors will no longer write admission orders.

At this point, if the ED doc thinks the patient needs to come in, then, as you describe, you’ll need to do an evaluation, dictate a consult, and decide on the disposition. Since the ED is technically an outpatient setting, you’ll need to bill your professional services accordingly, using CPT codes 99281-99288.

When it comes to the physical act of discharging a patient, I would use the discharge forms already present in your ED. In addition, I would make it a point to communicate directly with the nurse caring for the patient. My standard explanation would go something like this: “Dr. ED asked me to evaluate this patient. I saw them and told them that they could go home with appropriate follow-up. I’ve written/dictated a note and filled out the paperwork. Is there anything else that I need to do?”

More or less, I try to make it as easy for the nurse and the patient as possible. Please note that I did not include the ED doctor in that statement. It’s not that I don’t want you to be nice to them, but, depending on the physician, you can end up enabling their behavior, and pretty soon they’ll call you with every patient that might need admission. My favorite example was an older ED physician at a small community hospital who once called me to admit a patient. All he said was, “I’ve got a 67-year-old lady with abdominal pain.”

That’s it. He had not examined the patient, nor done any labs or studies. My mistake was just being available. Now, I know that’s what we do as hospitalists, but there’s a line between being helpful and getting worked over. So help when you can, and do it with a smile. But be firm.

One of the The Hospitalist newsmagazine’s features over the years is frequent articles educating physicians about Medicare reimbursement. Nothing wrong with that. Reimbursement for “sepsis” is better than for “urosepsis,” and that’s important for us to know.

However, I think it’s about time that we physicians take a stand and try to change some of the ridiculous word games going on in Medicare reimbursement circles. Why do we stand idly by and let some bureaucrat decree that if we write “urosepsis,” Medicare reimburses markedly less, even though we are treating exactly the same thing if we write “sepsis from UTI”? Why are we not fighting the asinine “bullet” system, in which we get substantially “downcoded” if we miss one trivial bullet in our physical exam that has no bearing on our assessment or plan for the patient? Why have we allowed this travesty to pass through unchallenged? Sure, this is the system now and has been, but do we need to continue to accept these inane reimbursement mechanisms?

I propose we develop a team from within SHM, maybe with some help from other physician organizations, to infiltrate, badger, or whatever it takes to advocate change to a reimbursement system that is more intuitive to physicians. The system should reimburse us for the value we add to the patient encounter. For example, how about reimbursement for nonprocedural visits measured not on history/exam bullets but on the complexity of your assessment and plan, including patient/family counseling and/ or care coordination?

Then we can read articles showing what we are doing to change/improve the Medicare reimbursement landscape instead of just learning how to comply with the current system.

Jim Fulmer, MD, site medical director,

Baptist Primary Care Hospitalist System,

Baptist Medical Center— Downtown Campus,

One of the The Hospitalist newsmagazine’s features over the years is frequent articles educating physicians about Medicare reimbursement. Nothing wrong with that. Reimbursement for “sepsis” is better than for “urosepsis,” and that’s important for us to know.

However, I think it’s about time that we physicians take a stand and try to change some of the ridiculous word games going on in Medicare reimbursement circles. Why do we stand idly by and let some bureaucrat decree that if we write “urosepsis,” Medicare reimburses markedly less, even though we are treating exactly the same thing if we write “sepsis from UTI”? Why are we not fighting the asinine “bullet” system, in which we get substantially “downcoded” if we miss one trivial bullet in our physical exam that has no bearing on our assessment or plan for the patient? Why have we allowed this travesty to pass through unchallenged? Sure, this is the system now and has been, but do we need to continue to accept these inane reimbursement mechanisms?

I propose we develop a team from within SHM, maybe with some help from other physician organizations, to infiltrate, badger, or whatever it takes to advocate change to a reimbursement system that is more intuitive to physicians. The system should reimburse us for the value we add to the patient encounter. For example, how about reimbursement for nonprocedural visits measured not on history/exam bullets but on the complexity of your assessment and plan, including patient/family counseling and/ or care coordination?

Then we can read articles showing what we are doing to change/improve the Medicare reimbursement landscape instead of just learning how to comply with the current system.

Jim Fulmer, MD, site medical director,

Baptist Primary Care Hospitalist System,

Baptist Medical Center— Downtown Campus,

One of the The Hospitalist newsmagazine’s features over the years is frequent articles educating physicians about Medicare reimbursement. Nothing wrong with that. Reimbursement for “sepsis” is better than for “urosepsis,” and that’s important for us to know.

However, I think it’s about time that we physicians take a stand and try to change some of the ridiculous word games going on in Medicare reimbursement circles. Why do we stand idly by and let some bureaucrat decree that if we write “urosepsis,” Medicare reimburses markedly less, even though we are treating exactly the same thing if we write “sepsis from UTI”? Why are we not fighting the asinine “bullet” system, in which we get substantially “downcoded” if we miss one trivial bullet in our physical exam that has no bearing on our assessment or plan for the patient? Why have we allowed this travesty to pass through unchallenged? Sure, this is the system now and has been, but do we need to continue to accept these inane reimbursement mechanisms?

I propose we develop a team from within SHM, maybe with some help from other physician organizations, to infiltrate, badger, or whatever it takes to advocate change to a reimbursement system that is more intuitive to physicians. The system should reimburse us for the value we add to the patient encounter. For example, how about reimbursement for nonprocedural visits measured not on history/exam bullets but on the complexity of your assessment and plan, including patient/family counseling and/ or care coordination?

Then we can read articles showing what we are doing to change/improve the Medicare reimbursement landscape instead of just learning how to comply with the current system.

Jim Fulmer, MD, site medical director,

Baptist Primary Care Hospitalist System,

Baptist Medical Center— Downtown Campus,

I would broaden the comment in the April 2012 article “10 Things Hospitalists Should Know about Infectious Diseases” regarding culturing decubitus ulcers to: “Do not swab any superficial dermatologic wound without sterilizing the surface and then subsequently expressing a sample from the underlying tissue.” I tell my trainees that, unless they sterilize, they might as well culture their ties and send that instead.

Clifford A. Kaye, MD, assistant professor,

Wayne State University SOM,

associate medical director of quality and hospital utilization,

Henry Ford Hospital, Detroit

I would broaden the comment in the April 2012 article “10 Things Hospitalists Should Know about Infectious Diseases” regarding culturing decubitus ulcers to: “Do not swab any superficial dermatologic wound without sterilizing the surface and then subsequently expressing a sample from the underlying tissue.” I tell my trainees that, unless they sterilize, they might as well culture their ties and send that instead.

Clifford A. Kaye, MD, assistant professor,

Wayne State University SOM,

associate medical director of quality and hospital utilization,

Henry Ford Hospital, Detroit

I would broaden the comment in the April 2012 article “10 Things Hospitalists Should Know about Infectious Diseases” regarding culturing decubitus ulcers to: “Do not swab any superficial dermatologic wound without sterilizing the surface and then subsequently expressing a sample from the underlying tissue.” I tell my trainees that, unless they sterilize, they might as well culture their ties and send that instead.

Clifford A. Kaye, MD, assistant professor,

Wayne State University SOM,

associate medical director of quality and hospital utilization,

Henry Ford Hospital, Detroit

ATLANTA – The incidence of Clostridium difficile infection in children in Monroe County, N.Y., was low, and most cases were mild and community acquired during 2009-2011, but a high proportion of children affected had underlying chronic medical conditions, surveillance data show.

Many cases in children followed exposure to traditional risk factors in the 2 weeks preceding C. difficile infection, including use of antibiotics in 48% of cases, and exposure to proton pump inhibitors in 15% of cases, Rebecca C. Smith reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo courtesy CDC/D.Holdeman

Surveillance for C. difficile infection in Monroe County was part of a Centers for Disease Control and Prevention Emerging Infections Program project initiated because of an increase in infections in hospitalized children, as well as increases of severe disease acquired in the community in individuals with no known exposures to risk factors such as health care and antibiotics. These increases occurred following emergence of the highly toxic, epidemic BI/NAP1/027 strain of C. difficile, said Ms. Smith of the University of Rochester (N.Y.).

Of 3,351 cases of C. difficile infection identified during the 2-year surveillance conducted between October 2009, and October 2011, 115 (3%) were in children, for a yearly incidence of 33.5 cases per 100,000 population. The median age of pediatric patients in this study was 5 years, with those aged 12-23 months comprising 24% of cases, she noted.

Most pediatric cases (71%) were community acquired, and 4 (3%) of the 115 children were hospitalized for the C. difficile infection.

Stool samples were collected in 31 children, and of these 90% grew C. difficile, and 26% of those were NAP1, Ms. Smith said.

Recurrences occurred in 23% of cases, which was a rate similar to that seen in the adult population with C. difficile infection, she noted.

Importantly, 64% of the children had an underlying medical condition. The underlying medical conditions in children with C. difficile infection included asthma, malignancy, presence of a G-tube, or failure to thrive, and these conditions may have increased the likelihood of having true disease, Ms. Smith said.

The findings suggest that further investigation of the risk of C. difficile infection in children with no traditional risk factors is warranted, she concluded.

Ms. Smith said she had had no relevant financial disclosures.

ATLANTA – The incidence of Clostridium difficile infection in children in Monroe County, N.Y., was low, and most cases were mild and community acquired during 2009-2011, but a high proportion of children affected had underlying chronic medical conditions, surveillance data show.

Many cases in children followed exposure to traditional risk factors in the 2 weeks preceding C. difficile infection, including use of antibiotics in 48% of cases, and exposure to proton pump inhibitors in 15% of cases, Rebecca C. Smith reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo courtesy CDC/D.Holdeman

Surveillance for C. difficile infection in Monroe County was part of a Centers for Disease Control and Prevention Emerging Infections Program project initiated because of an increase in infections in hospitalized children, as well as increases of severe disease acquired in the community in individuals with no known exposures to risk factors such as health care and antibiotics. These increases occurred following emergence of the highly toxic, epidemic BI/NAP1/027 strain of C. difficile, said Ms. Smith of the University of Rochester (N.Y.).

Of 3,351 cases of C. difficile infection identified during the 2-year surveillance conducted between October 2009, and October 2011, 115 (3%) were in children, for a yearly incidence of 33.5 cases per 100,000 population. The median age of pediatric patients in this study was 5 years, with those aged 12-23 months comprising 24% of cases, she noted.

Most pediatric cases (71%) were community acquired, and 4 (3%) of the 115 children were hospitalized for the C. difficile infection.

Stool samples were collected in 31 children, and of these 90% grew C. difficile, and 26% of those were NAP1, Ms. Smith said.

Recurrences occurred in 23% of cases, which was a rate similar to that seen in the adult population with C. difficile infection, she noted.

Importantly, 64% of the children had an underlying medical condition. The underlying medical conditions in children with C. difficile infection included asthma, malignancy, presence of a G-tube, or failure to thrive, and these conditions may have increased the likelihood of having true disease, Ms. Smith said.

The findings suggest that further investigation of the risk of C. difficile infection in children with no traditional risk factors is warranted, she concluded.

Ms. Smith said she had had no relevant financial disclosures.

ATLANTA – The incidence of Clostridium difficile infection in children in Monroe County, N.Y., was low, and most cases were mild and community acquired during 2009-2011, but a high proportion of children affected had underlying chronic medical conditions, surveillance data show.

Many cases in children followed exposure to traditional risk factors in the 2 weeks preceding C. difficile infection, including use of antibiotics in 48% of cases, and exposure to proton pump inhibitors in 15% of cases, Rebecca C. Smith reported in a poster at the International Conference on Emerging Infectious Diseases.

Photo courtesy CDC/D.Holdeman

Surveillance for C. difficile infection in Monroe County was part of a Centers for Disease Control and Prevention Emerging Infections Program project initiated because of an increase in infections in hospitalized children, as well as increases of severe disease acquired in the community in individuals with no known exposures to risk factors such as health care and antibiotics. These increases occurred following emergence of the highly toxic, epidemic BI/NAP1/027 strain of C. difficile, said Ms. Smith of the University of Rochester (N.Y.).

Of 3,351 cases of C. difficile infection identified during the 2-year surveillance conducted between October 2009, and October 2011, 115 (3%) were in children, for a yearly incidence of 33.5 cases per 100,000 population. The median age of pediatric patients in this study was 5 years, with those aged 12-23 months comprising 24% of cases, she noted.

Most pediatric cases (71%) were community acquired, and 4 (3%) of the 115 children were hospitalized for the C. difficile infection.

Stool samples were collected in 31 children, and of these 90% grew C. difficile, and 26% of those were NAP1, Ms. Smith said.

Recurrences occurred in 23% of cases, which was a rate similar to that seen in the adult population with C. difficile infection, she noted.

Importantly, 64% of the children had an underlying medical condition. The underlying medical conditions in children with C. difficile infection included asthma, malignancy, presence of a G-tube, or failure to thrive, and these conditions may have increased the likelihood of having true disease, Ms. Smith said.

The findings suggest that further investigation of the risk of C. difficile infection in children with no traditional risk factors is warranted, she concluded.

Ms. Smith said she had had no relevant financial disclosures.

The septate uterus is not only the most common Müllerian anomaly, it is the uterine malformation associated with the poorest reproductive outcomes, including recurrent pregnancy loss, preterm labor, malpresentation, and probably infertility. Although many patients with a uterine septum are asymptomatic and conceive and deliver without any difficulty, those who do have poor outcomes can benefit from transection of the septum.

The simplicity of hysteroscopic septoplasty, with its low rates of intraoperative complications and postoperative sequelae, provides experienced gynecologic surgeons with the opportunity to remarkably improve reproductive and obstetric outcomes for their patients with this anomaly.

The procedure has proven to be safe and effective for women with a history of recurrent miscarriage and other poor reproductive outcomes. Although a causal relationship between the septate uterus and infertility remains unproven, encouraging findings from numerous retrospective and observational studies are supporting the procedure’s use in patients with unexplained primary infertility as well.

Incidence and Effects

Müllerian anomalies are an embryologic phenomenon of the female reproductive tract. The anomalies are the result of a defect in the elongation, fusion, canalization, or septal reabsorption of the Müllerian/paramesonephric ducts.

Normally, at approximately 9 weeks’ gestation, these steps occur without incident and result in the creation of a single unified uterine cavity. In some cases, however, incomplete or failed reabsorption of the intervening partition of Müllerian products results in a persistent fibromuscular uterine septum. The extent of the septum varies; usually, it partially affects the uterine cavity rather than completely dividing it.

The septate uterus, the most common type of Müllerian anomaly, has been estimated to occur in 3%-7% of the general population. Its clinical sequelae include increased rates of spontaneous abortion, preterm delivery, intrauterine growth restriction, and malpresentation, compared with rates in women without a septum, as well as a higher rate of cesarean delivery.

Estimates of pregnancy rates in patients with a septate uterus have ranged from 5% to 40%, and miscarriage rates of 70%-90% have been reported. Thus, live birth rates in this population are poor.

Although uterine septa are closely related to recurrent miscarriage, the effect of the septate uterus on fertility is controversial. Some experts have proposed that the septate uterus may at least contribute to otherwise unexplained infertility by adversely affecting implantation. The endometrium overlying the septum may be different from the neighboring endometrium within the uterine cavity, it is believed, although this relationship is not yet directly correlated with primary infertility.

Dr. Luigi Fedele and his colleagues in Milan reported ultrastructural changes in biopsy sites from the septum, compared with the sites in the lateral uterine wall, using scanning electron microcopy. These histological factors included reductions in the number of glandular ostia, an irregular distribution of glandular ostia, incomplete ciliogenesis, and reductions in the ciliated cell ratio. The authors further concluded that septal tissue had decreased sensitivity to steroid hormones (Fertil. Steril. 1996;65:750-2).

Indications for Surgery

Currently, indications for surgical correction of a uterine septum include pelvic pain, endometriosis, an obstructing phenomenon, recurrent miscarriage, and history of preterm delivery.

Infertility is a controversial indication for surgery, as its association with the septate uterus has not been demonstrated by randomized studies. Several observational studies, however, have shown promising results with postoperative pregnancy rates of 25%-70% in patients with primary infertility, and there is consequently a movement to expand the use of hysteroscopic septoplasty to this subset of patients.

In one systematic review of 18 studies (including one retrospective cohort study of 64 women conducted by the review’s authors), the overall pregnancy rate after hysteroscopic septoplasty was 60% and the overall live birth rate was 45% (Reprod. Biol. Endocrinol. 2010;8:52-60).

A more recently published prospective study of women with unexplained primary infertility yielded remarkable results. Of 88 patients who underwent septoplasty, 48% conceived within a mean time to conception of approximately 7 months. Nearly 80% of these women conceived spontaneously, and more than 80% had live births. Approximately 71% of the deliveries were vaginal.

The only identifiable factor associated with reproductive failure in this study was a uterine septum. Patients had unexplained primary infertility for at least 48 months, and the study excluded patients with any history of miscarriage, abortion, or other factors that could contribute to infertility, such as endometriosis (Eur. J. Obstet. Gynecol. Reprod. Biol. 2011;155:54-7).

Diagnosis

Many imaging modalities have been used in the diagnosis of a uterine septum, including hysterosalpingogram (HSG), 2D and 3D ultrasound, saline infusion sonohysterography, and MRI. Müllerian anomalies may be paired with anomalies of the urinary tract, although the correlation with uterine septa is present less frequently than with other uterine anomalies. Nevertheless, evaluation of the urinary tract should be performed as part of the diagnostic work-up in patients with anomalies and thus may influence the diagnostic approach.

An HSG can elucidate the contour of the endometrial cavity and any communications including tubal patency. HSG is not universally considered a reliable diagnostic strategy, however, as the serosal surface of the uterus is not examined.

Images courtesy Dr. Megan Daw

By contrast, as Dr. Fedele has demonstrated, sensitivity and specificity may be up to 100% with the use of 3D sonography. Ultrasound also can provide an assessment of other pelvic structures, such as ovaries and kidneys, that may contribute to a patient’s symptoms or be associated with Müllerian anomalies.

MRI is another noninvasive diagnostic strategy for characterizing Müllerian anomalies. It is both sensitive and specific, and is considered a valuable strategy as it allows for thorough evaluation of both the internal and external contour of the uterus.

Although advancements in MRI and ultrasound have improved diagnostic accuracy, concurrent laparoscopy at the time of hysteroscopic treatment remains the standard in confirming the diagnostic impressions formed by initial imaging. At our institution, we employ a combination of in-office 2D and 3D ultrasound, as well as saline infusion sonohysterography, and then confirm our findings laparoscopically at the time of surgery.

Treatment, Complication Risk

Uterine septa classically were treated with abdominal surgery, but advances in operative hysteroscopy have led to equally efficacious treatment with the advantage of decreased morbidity.

Potential intraoperative complications of hysteroscopic transection of uterine septa include bleeding, distention media overload, and perforation, with an associated risk of damage to nearby structures. Generally, septa are avascular, making the risk of both hemorrhage and distention media overload quite minimal. These complications are on the order of less than 1%, and typically the procedure is performed without incident on an outpatient basis.

Delayed complications of hysteroscopic septoplasty include the formation of intrauterine adhesions and the risk of uterine rupture with subsequent pregnancies. Although case reports of uterine rupture after hysteroscopic septoplasty exist, rupture is a very rare event because the integrity of the myometrium is generally preserved.

Adhesion formation, however, has been reported in up to approximately 7% of cases following hysteroscopic transection of uterine septum, according to a review published last year (Semin. Reprod. Med. 2011;29:83-94). Adhesion formation can further compromise the gestational performance of these patients.

Operative Technique

In preparation for operative hysteroscopy, many surgeons recommend priming the endometrial lining to provide optimal visualization. Progestins, oral contraceptive pills (OCs), or a GnRH analog can be used for this purpose. Alternatively, the procedure may be coordinated or timed with the patient’s early proliferative phase.

Hysteroscopic treatment involves incising the uterine septum and allowing the fibromuscular tissue to retract to the level of the surrounding endometrium. Surgeons have used microscissors, electrosurgery, or even fiberoptic laser energy, although this latter technique is currently less common given its expense, manipulation difficulties, and requirement for specialized training.

Although energy-based techniques provide hemostasis and may offer greater ease to a procedure involving a thick septum, use of these techniques increases the risk of postoperative intrauterine adhesion formation from endometrial and myometrial thermal damage. The use of microscissors, an energy-free technique, avoids thermal damage to the surrounding tissue and the subsequent increased risk of intrauterine adhesive disease.

Images courtesy Dr. Megan Daw

A 12- or 25-degree lens provides accurate and continuous orientation of the ostia and instruments. A 5-7 Fr semi-rigid scissors offer sturdiness and maneuverability.

The surgical technique involves the incision of the septum equidistant between the anterior and posterior walls and traveling toward the fundus without inciting trauma to the myometrium of the fundus. Specifically, the septum is incised with both ostia in the visual field and midway between the anterior and posterior wall of the uterus. The incision is extended cephalad to the level of the uterine fundus.

If a broad septum limits visualization of both ostia, sequential thinning incisions are made along each side of the septum from the apex to the fundus. These incisions create a wedge that can ultimately be transected. The end point may be subtle, but continuous movement from one ostium to the other with the hysteroscope, and a uniform appearance of the uterine fundus, should be achieved. Bleeding may be an additional indication that the septum has been completely transected as this indicates myometrial disruption.

A complete septum is considered a rare phenomenon and may best be surgically treated only by providers with advanced hysteroscopic experience. In this case, visualization of the ectocervix must first be maximized. The initiation of the transection can be performed using a handheld instrument such as scissors, blade, or electrosurgical pencil and then continued hysteroscopically in a manner similar to transection of a partial septum.

Concomitant laparoscopic visualization can confirm prior findings revealed by imaging, provide assurance that the bowel is not adherent to the peritoneal surface of the uterus, and reveal proximity of the hysteroscopic instruments to the uterine serosal surface, thus decreasing risk of perforation during the procedure. Additionally, blanching of the uterine serosa or visualization of the hysteroscopic light can illustrate proximity to the serosal surface.

Coexisting pelvic pathology also can be diagnosed and treated at the time of the hysteroscopic procedure, as in the case of endometriosis.

Postop Care, Follow-Up

Postoperative care and follow-up must include strategies for preventing intrauterine adhesion formation and for confirming success of the procedure.

Multiple methods, from the placement of an intrauterine device or catheter to estrogen supplementation, have been proposed to minimize or prevent intrauterine adhesion formation following hysteroscopic septoplasty.

The IUD initially used for the purpose of separating endometrial surfaces over the operative site during healing was the Lippe’s loop – an inert device consisting of a thin polyethylene wire bent into a series of "S" shapes. It was removed from the U.S. market in the 1980s and is no longer widely available. The two currently approved IUDs – copper-based or progestin-containing – both raise concerns postoperatively, as copper can cause inflammation and progestins cause thinning of the endometrium lining.

For these reasons and in the setting of poor supportive data, IUDs are no longer used following hysteroscopic septoplasty.

Intrauterine catheters or stents are sometimes used following septoplasty under the same philosophy espoused by the IUD proponents – that adhesion formation can be prevented by the physical separation of endometrial surfaces during healing.

The surgeon should be extremely mindful of intrauterine pressure when a stent is placed, as the theoretical risk of uterine rupture exists if the myometrium is significantly disrupted during the procedure. Stents include a pediatric Foley balloon or specific intrauterine devices sold commercially.

Supplemental estrogen may be used to stimulate endometrial proliferation and, therefore, promote healing over the operative site. Multiple regimens exist and are sometimes paired with progestins. No standard regimen is reported in the literature and, thus, this choice depends on one’s familiarity and comfort.

Dr. Megan Daw is an AAGL/SRS fellow in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill. She matriculated at the University of North Carolina at Chapel Hill, then completed her residency in obstetrics and gynecology at the University of California at San Francisco in June 2010. Dr. Daw said that she has no disclosures to report.

The septate uterus is not only the most common Müllerian anomaly, it is the uterine malformation associated with the poorest reproductive outcomes, including recurrent pregnancy loss, preterm labor, malpresentation, and probably infertility. Although many patients with a uterine septum are asymptomatic and conceive and deliver without any difficulty, those who do have poor outcomes can benefit from transection of the septum.

The simplicity of hysteroscopic septoplasty, with its low rates of intraoperative complications and postoperative sequelae, provides experienced gynecologic surgeons with the opportunity to remarkably improve reproductive and obstetric outcomes for their patients with this anomaly.

The procedure has proven to be safe and effective for women with a history of recurrent miscarriage and other poor reproductive outcomes. Although a causal relationship between the septate uterus and infertility remains unproven, encouraging findings from numerous retrospective and observational studies are supporting the procedure’s use in patients with unexplained primary infertility as well.

Incidence and Effects

Müllerian anomalies are an embryologic phenomenon of the female reproductive tract. The anomalies are the result of a defect in the elongation, fusion, canalization, or septal reabsorption of the Müllerian/paramesonephric ducts.

Normally, at approximately 9 weeks’ gestation, these steps occur without incident and result in the creation of a single unified uterine cavity. In some cases, however, incomplete or failed reabsorption of the intervening partition of Müllerian products results in a persistent fibromuscular uterine septum. The extent of the septum varies; usually, it partially affects the uterine cavity rather than completely dividing it.

The septate uterus, the most common type of Müllerian anomaly, has been estimated to occur in 3%-7% of the general population. Its clinical sequelae include increased rates of spontaneous abortion, preterm delivery, intrauterine growth restriction, and malpresentation, compared with rates in women without a septum, as well as a higher rate of cesarean delivery.

Estimates of pregnancy rates in patients with a septate uterus have ranged from 5% to 40%, and miscarriage rates of 70%-90% have been reported. Thus, live birth rates in this population are poor.

Although uterine septa are closely related to recurrent miscarriage, the effect of the septate uterus on fertility is controversial. Some experts have proposed that the septate uterus may at least contribute to otherwise unexplained infertility by adversely affecting implantation. The endometrium overlying the septum may be different from the neighboring endometrium within the uterine cavity, it is believed, although this relationship is not yet directly correlated with primary infertility.

Dr. Luigi Fedele and his colleagues in Milan reported ultrastructural changes in biopsy sites from the septum, compared with the sites in the lateral uterine wall, using scanning electron microcopy. These histological factors included reductions in the number of glandular ostia, an irregular distribution of glandular ostia, incomplete ciliogenesis, and reductions in the ciliated cell ratio. The authors further concluded that septal tissue had decreased sensitivity to steroid hormones (Fertil. Steril. 1996;65:750-2).

Indications for Surgery

Currently, indications for surgical correction of a uterine septum include pelvic pain, endometriosis, an obstructing phenomenon, recurrent miscarriage, and history of preterm delivery.

Infertility is a controversial indication for surgery, as its association with the septate uterus has not been demonstrated by randomized studies. Several observational studies, however, have shown promising results with postoperative pregnancy rates of 25%-70% in patients with primary infertility, and there is consequently a movement to expand the use of hysteroscopic septoplasty to this subset of patients.

In one systematic review of 18 studies (including one retrospective cohort study of 64 women conducted by the review’s authors), the overall pregnancy rate after hysteroscopic septoplasty was 60% and the overall live birth rate was 45% (Reprod. Biol. Endocrinol. 2010;8:52-60).

A more recently published prospective study of women with unexplained primary infertility yielded remarkable results. Of 88 patients who underwent septoplasty, 48% conceived within a mean time to conception of approximately 7 months. Nearly 80% of these women conceived spontaneously, and more than 80% had live births. Approximately 71% of the deliveries were vaginal.

The only identifiable factor associated with reproductive failure in this study was a uterine septum. Patients had unexplained primary infertility for at least 48 months, and the study excluded patients with any history of miscarriage, abortion, or other factors that could contribute to infertility, such as endometriosis (Eur. J. Obstet. Gynecol. Reprod. Biol. 2011;155:54-7).

Diagnosis

Many imaging modalities have been used in the diagnosis of a uterine septum, including hysterosalpingogram (HSG), 2D and 3D ultrasound, saline infusion sonohysterography, and MRI. Müllerian anomalies may be paired with anomalies of the urinary tract, although the correlation with uterine septa is present less frequently than with other uterine anomalies. Nevertheless, evaluation of the urinary tract should be performed as part of the diagnostic work-up in patients with anomalies and thus may influence the diagnostic approach.

An HSG can elucidate the contour of the endometrial cavity and any communications including tubal patency. HSG is not universally considered a reliable diagnostic strategy, however, as the serosal surface of the uterus is not examined.

Images courtesy Dr. Megan Daw

By contrast, as Dr. Fedele has demonstrated, sensitivity and specificity may be up to 100% with the use of 3D sonography. Ultrasound also can provide an assessment of other pelvic structures, such as ovaries and kidneys, that may contribute to a patient’s symptoms or be associated with Müllerian anomalies.

MRI is another noninvasive diagnostic strategy for characterizing Müllerian anomalies. It is both sensitive and specific, and is considered a valuable strategy as it allows for thorough evaluation of both the internal and external contour of the uterus.

Although advancements in MRI and ultrasound have improved diagnostic accuracy, concurrent laparoscopy at the time of hysteroscopic treatment remains the standard in confirming the diagnostic impressions formed by initial imaging. At our institution, we employ a combination of in-office 2D and 3D ultrasound, as well as saline infusion sonohysterography, and then confirm our findings laparoscopically at the time of surgery.

Treatment, Complication Risk

Uterine septa classically were treated with abdominal surgery, but advances in operative hysteroscopy have led to equally efficacious treatment with the advantage of decreased morbidity.

Potential intraoperative complications of hysteroscopic transection of uterine septa include bleeding, distention media overload, and perforation, with an associated risk of damage to nearby structures. Generally, septa are avascular, making the risk of both hemorrhage and distention media overload quite minimal. These complications are on the order of less than 1%, and typically the procedure is performed without incident on an outpatient basis.

Delayed complications of hysteroscopic septoplasty include the formation of intrauterine adhesions and the risk of uterine rupture with subsequent pregnancies. Although case reports of uterine rupture after hysteroscopic septoplasty exist, rupture is a very rare event because the integrity of the myometrium is generally preserved.

Adhesion formation, however, has been reported in up to approximately 7% of cases following hysteroscopic transection of uterine septum, according to a review published last year (Semin. Reprod. Med. 2011;29:83-94). Adhesion formation can further compromise the gestational performance of these patients.

Operative Technique

In preparation for operative hysteroscopy, many surgeons recommend priming the endometrial lining to provide optimal visualization. Progestins, oral contraceptive pills (OCs), or a GnRH analog can be used for this purpose. Alternatively, the procedure may be coordinated or timed with the patient’s early proliferative phase.

Hysteroscopic treatment involves incising the uterine septum and allowing the fibromuscular tissue to retract to the level of the surrounding endometrium. Surgeons have used microscissors, electrosurgery, or even fiberoptic laser energy, although this latter technique is currently less common given its expense, manipulation difficulties, and requirement for specialized training.

Although energy-based techniques provide hemostasis and may offer greater ease to a procedure involving a thick septum, use of these techniques increases the risk of postoperative intrauterine adhesion formation from endometrial and myometrial thermal damage. The use of microscissors, an energy-free technique, avoids thermal damage to the surrounding tissue and the subsequent increased risk of intrauterine adhesive disease.

Images courtesy Dr. Megan Daw

A 12- or 25-degree lens provides accurate and continuous orientation of the ostia and instruments. A 5-7 Fr semi-rigid scissors offer sturdiness and maneuverability.

The surgical technique involves the incision of the septum equidistant between the anterior and posterior walls and traveling toward the fundus without inciting trauma to the myometrium of the fundus. Specifically, the septum is incised with both ostia in the visual field and midway between the anterior and posterior wall of the uterus. The incision is extended cephalad to the level of the uterine fundus.

If a broad septum limits visualization of both ostia, sequential thinning incisions are made along each side of the septum from the apex to the fundus. These incisions create a wedge that can ultimately be transected. The end point may be subtle, but continuous movement from one ostium to the other with the hysteroscope, and a uniform appearance of the uterine fundus, should be achieved. Bleeding may be an additional indication that the septum has been completely transected as this indicates myometrial disruption.

A complete septum is considered a rare phenomenon and may best be surgically treated only by providers with advanced hysteroscopic experience. In this case, visualization of the ectocervix must first be maximized. The initiation of the transection can be performed using a handheld instrument such as scissors, blade, or electrosurgical pencil and then continued hysteroscopically in a manner similar to transection of a partial septum.

Concomitant laparoscopic visualization can confirm prior findings revealed by imaging, provide assurance that the bowel is not adherent to the peritoneal surface of the uterus, and reveal proximity of the hysteroscopic instruments to the uterine serosal surface, thus decreasing risk of perforation during the procedure. Additionally, blanching of the uterine serosa or visualization of the hysteroscopic light can illustrate proximity to the serosal surface.

Coexisting pelvic pathology also can be diagnosed and treated at the time of the hysteroscopic procedure, as in the case of endometriosis.

Postop Care, Follow-Up

Postoperative care and follow-up must include strategies for preventing intrauterine adhesion formation and for confirming success of the procedure.

Multiple methods, from the placement of an intrauterine device or catheter to estrogen supplementation, have been proposed to minimize or prevent intrauterine adhesion formation following hysteroscopic septoplasty.

The IUD initially used for the purpose of separating endometrial surfaces over the operative site during healing was the Lippe’s loop – an inert device consisting of a thin polyethylene wire bent into a series of "S" shapes. It was removed from the U.S. market in the 1980s and is no longer widely available. The two currently approved IUDs – copper-based or progestin-containing – both raise concerns postoperatively, as copper can cause inflammation and progestins cause thinning of the endometrium lining.

For these reasons and in the setting of poor supportive data, IUDs are no longer used following hysteroscopic septoplasty.

Intrauterine catheters or stents are sometimes used following septoplasty under the same philosophy espoused by the IUD proponents – that adhesion formation can be prevented by the physical separation of endometrial surfaces during healing.

The surgeon should be extremely mindful of intrauterine pressure when a stent is placed, as the theoretical risk of uterine rupture exists if the myometrium is significantly disrupted during the procedure. Stents include a pediatric Foley balloon or specific intrauterine devices sold commercially.

Supplemental estrogen may be used to stimulate endometrial proliferation and, therefore, promote healing over the operative site. Multiple regimens exist and are sometimes paired with progestins. No standard regimen is reported in the literature and, thus, this choice depends on one’s familiarity and comfort.

Dr. Megan Daw is an AAGL/SRS fellow in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill. She matriculated at the University of North Carolina at Chapel Hill, then completed her residency in obstetrics and gynecology at the University of California at San Francisco in June 2010. Dr. Daw said that she has no disclosures to report.

The septate uterus is not only the most common Müllerian anomaly, it is the uterine malformation associated with the poorest reproductive outcomes, including recurrent pregnancy loss, preterm labor, malpresentation, and probably infertility. Although many patients with a uterine septum are asymptomatic and conceive and deliver without any difficulty, those who do have poor outcomes can benefit from transection of the septum.

The simplicity of hysteroscopic septoplasty, with its low rates of intraoperative complications and postoperative sequelae, provides experienced gynecologic surgeons with the opportunity to remarkably improve reproductive and obstetric outcomes for their patients with this anomaly.

The procedure has proven to be safe and effective for women with a history of recurrent miscarriage and other poor reproductive outcomes. Although a causal relationship between the septate uterus and infertility remains unproven, encouraging findings from numerous retrospective and observational studies are supporting the procedure’s use in patients with unexplained primary infertility as well.

Incidence and Effects

Müllerian anomalies are an embryologic phenomenon of the female reproductive tract. The anomalies are the result of a defect in the elongation, fusion, canalization, or septal reabsorption of the Müllerian/paramesonephric ducts.

Normally, at approximately 9 weeks’ gestation, these steps occur without incident and result in the creation of a single unified uterine cavity. In some cases, however, incomplete or failed reabsorption of the intervening partition of Müllerian products results in a persistent fibromuscular uterine septum. The extent of the septum varies; usually, it partially affects the uterine cavity rather than completely dividing it.

The septate uterus, the most common type of Müllerian anomaly, has been estimated to occur in 3%-7% of the general population. Its clinical sequelae include increased rates of spontaneous abortion, preterm delivery, intrauterine growth restriction, and malpresentation, compared with rates in women without a septum, as well as a higher rate of cesarean delivery.

Estimates of pregnancy rates in patients with a septate uterus have ranged from 5% to 40%, and miscarriage rates of 70%-90% have been reported. Thus, live birth rates in this population are poor.

Although uterine septa are closely related to recurrent miscarriage, the effect of the septate uterus on fertility is controversial. Some experts have proposed that the septate uterus may at least contribute to otherwise unexplained infertility by adversely affecting implantation. The endometrium overlying the septum may be different from the neighboring endometrium within the uterine cavity, it is believed, although this relationship is not yet directly correlated with primary infertility.

Dr. Luigi Fedele and his colleagues in Milan reported ultrastructural changes in biopsy sites from the septum, compared with the sites in the lateral uterine wall, using scanning electron microcopy. These histological factors included reductions in the number of glandular ostia, an irregular distribution of glandular ostia, incomplete ciliogenesis, and reductions in the ciliated cell ratio. The authors further concluded that septal tissue had decreased sensitivity to steroid hormones (Fertil. Steril. 1996;65:750-2).

Indications for Surgery

Currently, indications for surgical correction of a uterine septum include pelvic pain, endometriosis, an obstructing phenomenon, recurrent miscarriage, and history of preterm delivery.

Infertility is a controversial indication for surgery, as its association with the septate uterus has not been demonstrated by randomized studies. Several observational studies, however, have shown promising results with postoperative pregnancy rates of 25%-70% in patients with primary infertility, and there is consequently a movement to expand the use of hysteroscopic septoplasty to this subset of patients.

In one systematic review of 18 studies (including one retrospective cohort study of 64 women conducted by the review’s authors), the overall pregnancy rate after hysteroscopic septoplasty was 60% and the overall live birth rate was 45% (Reprod. Biol. Endocrinol. 2010;8:52-60).

A more recently published prospective study of women with unexplained primary infertility yielded remarkable results. Of 88 patients who underwent septoplasty, 48% conceived within a mean time to conception of approximately 7 months. Nearly 80% of these women conceived spontaneously, and more than 80% had live births. Approximately 71% of the deliveries were vaginal.

The only identifiable factor associated with reproductive failure in this study was a uterine septum. Patients had unexplained primary infertility for at least 48 months, and the study excluded patients with any history of miscarriage, abortion, or other factors that could contribute to infertility, such as endometriosis (Eur. J. Obstet. Gynecol. Reprod. Biol. 2011;155:54-7).

Diagnosis

Many imaging modalities have been used in the diagnosis of a uterine septum, including hysterosalpingogram (HSG), 2D and 3D ultrasound, saline infusion sonohysterography, and MRI. Müllerian anomalies may be paired with anomalies of the urinary tract, although the correlation with uterine septa is present less frequently than with other uterine anomalies. Nevertheless, evaluation of the urinary tract should be performed as part of the diagnostic work-up in patients with anomalies and thus may influence the diagnostic approach.

An HSG can elucidate the contour of the endometrial cavity and any communications including tubal patency. HSG is not universally considered a reliable diagnostic strategy, however, as the serosal surface of the uterus is not examined.

Images courtesy Dr. Megan Daw

By contrast, as Dr. Fedele has demonstrated, sensitivity and specificity may be up to 100% with the use of 3D sonography. Ultrasound also can provide an assessment of other pelvic structures, such as ovaries and kidneys, that may contribute to a patient’s symptoms or be associated with Müllerian anomalies.

MRI is another noninvasive diagnostic strategy for characterizing Müllerian anomalies. It is both sensitive and specific, and is considered a valuable strategy as it allows for thorough evaluation of both the internal and external contour of the uterus.

Although advancements in MRI and ultrasound have improved diagnostic accuracy, concurrent laparoscopy at the time of hysteroscopic treatment remains the standard in confirming the diagnostic impressions formed by initial imaging. At our institution, we employ a combination of in-office 2D and 3D ultrasound, as well as saline infusion sonohysterography, and then confirm our findings laparoscopically at the time of surgery.

Treatment, Complication Risk

Uterine septa classically were treated with abdominal surgery, but advances in operative hysteroscopy have led to equally efficacious treatment with the advantage of decreased morbidity.

Potential intraoperative complications of hysteroscopic transection of uterine septa include bleeding, distention media overload, and perforation, with an associated risk of damage to nearby structures. Generally, septa are avascular, making the risk of both hemorrhage and distention media overload quite minimal. These complications are on the order of less than 1%, and typically the procedure is performed without incident on an outpatient basis.

Delayed complications of hysteroscopic septoplasty include the formation of intrauterine adhesions and the risk of uterine rupture with subsequent pregnancies. Although case reports of uterine rupture after hysteroscopic septoplasty exist, rupture is a very rare event because the integrity of the myometrium is generally preserved.

Adhesion formation, however, has been reported in up to approximately 7% of cases following hysteroscopic transection of uterine septum, according to a review published last year (Semin. Reprod. Med. 2011;29:83-94). Adhesion formation can further compromise the gestational performance of these patients.

Operative Technique

In preparation for operative hysteroscopy, many surgeons recommend priming the endometrial lining to provide optimal visualization. Progestins, oral contraceptive pills (OCs), or a GnRH analog can be used for this purpose. Alternatively, the procedure may be coordinated or timed with the patient’s early proliferative phase.

Hysteroscopic treatment involves incising the uterine septum and allowing the fibromuscular tissue to retract to the level of the surrounding endometrium. Surgeons have used microscissors, electrosurgery, or even fiberoptic laser energy, although this latter technique is currently less common given its expense, manipulation difficulties, and requirement for specialized training.

Although energy-based techniques provide hemostasis and may offer greater ease to a procedure involving a thick septum, use of these techniques increases the risk of postoperative intrauterine adhesion formation from endometrial and myometrial thermal damage. The use of microscissors, an energy-free technique, avoids thermal damage to the surrounding tissue and the subsequent increased risk of intrauterine adhesive disease.

Images courtesy Dr. Megan Daw

A 12- or 25-degree lens provides accurate and continuous orientation of the ostia and instruments. A 5-7 Fr semi-rigid scissors offer sturdiness and maneuverability.

The surgical technique involves the incision of the septum equidistant between the anterior and posterior walls and traveling toward the fundus without inciting trauma to the myometrium of the fundus. Specifically, the septum is incised with both ostia in the visual field and midway between the anterior and posterior wall of the uterus. The incision is extended cephalad to the level of the uterine fundus.

If a broad septum limits visualization of both ostia, sequential thinning incisions are made along each side of the septum from the apex to the fundus. These incisions create a wedge that can ultimately be transected. The end point may be subtle, but continuous movement from one ostium to the other with the hysteroscope, and a uniform appearance of the uterine fundus, should be achieved. Bleeding may be an additional indication that the septum has been completely transected as this indicates myometrial disruption.

A complete septum is considered a rare phenomenon and may best be surgically treated only by providers with advanced hysteroscopic experience. In this case, visualization of the ectocervix must first be maximized. The initiation of the transection can be performed using a handheld instrument such as scissors, blade, or electrosurgical pencil and then continued hysteroscopically in a manner similar to transection of a partial septum.

Concomitant laparoscopic visualization can confirm prior findings revealed by imaging, provide assurance that the bowel is not adherent to the peritoneal surface of the uterus, and reveal proximity of the hysteroscopic instruments to the uterine serosal surface, thus decreasing risk of perforation during the procedure. Additionally, blanching of the uterine serosa or visualization of the hysteroscopic light can illustrate proximity to the serosal surface.

Coexisting pelvic pathology also can be diagnosed and treated at the time of the hysteroscopic procedure, as in the case of endometriosis.

Postop Care, Follow-Up

Postoperative care and follow-up must include strategies for preventing intrauterine adhesion formation and for confirming success of the procedure.

Multiple methods, from the placement of an intrauterine device or catheter to estrogen supplementation, have been proposed to minimize or prevent intrauterine adhesion formation following hysteroscopic septoplasty.

The IUD initially used for the purpose of separating endometrial surfaces over the operative site during healing was the Lippe’s loop – an inert device consisting of a thin polyethylene wire bent into a series of "S" shapes. It was removed from the U.S. market in the 1980s and is no longer widely available. The two currently approved IUDs – copper-based or progestin-containing – both raise concerns postoperatively, as copper can cause inflammation and progestins cause thinning of the endometrium lining.

For these reasons and in the setting of poor supportive data, IUDs are no longer used following hysteroscopic septoplasty.

Intrauterine catheters or stents are sometimes used following septoplasty under the same philosophy espoused by the IUD proponents – that adhesion formation can be prevented by the physical separation of endometrial surfaces during healing.

The surgeon should be extremely mindful of intrauterine pressure when a stent is placed, as the theoretical risk of uterine rupture exists if the myometrium is significantly disrupted during the procedure. Stents include a pediatric Foley balloon or specific intrauterine devices sold commercially.

Supplemental estrogen may be used to stimulate endometrial proliferation and, therefore, promote healing over the operative site. Multiple regimens exist and are sometimes paired with progestins. No standard regimen is reported in the literature and, thus, this choice depends on one’s familiarity and comfort.

Dr. Megan Daw is an AAGL/SRS fellow in minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill. She matriculated at the University of North Carolina at Chapel Hill, then completed her residency in obstetrics and gynecology at the University of California at San Francisco in June 2010. Dr. Daw said that she has no disclosures to report.

Nearly five years ago, when Nasim Afsar, MD, SFHM, was launching her career as a hospitalist at the University of California Los Angeles Medical Center, she began to appreciate the importance of quality issues for the field of hospital medicine.

Dr. Afsar, who recently was elected to the SHM board of directors, says, "I realized that evidence-based medicine should be the standard of care in hospitals, but we were nowhere near where we should be in addressing that at a systemic level."

Believing that her medical training had not fully prepared her for quality work, Dr. Afsar attended the Advanced Training Program at Intermountain Healthcare in Salt Lake City. "With that foundation, my focus ever since has been on improvement initiatives," she says.

In the years since, Dr. Afsar's quality responsibilities have grown steadily. She is now associate medical director of quality and safety at UCLA, executive director for quality and safety in its department of medicine, and director of quality for neurosurgery. That means about 80% of her work week is devoted to quality improvement (QI). And while her time seeing patients is less, she says the "clinical work is what inspires and motivates me, gives me my best ideas, and keeps me grounded."

Among the more than 40 quality and safety projects she has implemented at UCLA is "The ABCs of Hospitalized Patients," a multidisciplinary checklist designed to reduce the risk of eight common hospital-acquired conditions. "Within three weeks of implementing it, we started seeing significant improvement in every area, and we have been able to sustain that," she says. In 2009, she implemented a systemwide QI curriculum for the residents and fellows at UCLA.

Dr. Afsar, chair of SHM's Hospital Quality and Patient Safety Committee, says HM is challenged to make these kinds of quality approaches the standard of practice nationwide.

"Different institutions are doing different pieces of the quality movement very well," and SHM and its leaders on the board need to find a way to disseminate those best practices and integrate them into hospital practice, she says. "There are no simple ways to do that, but we know there are a lot of solutions out there."

Nearly five years ago, when Nasim Afsar, MD, SFHM, was launching her career as a hospitalist at the University of California Los Angeles Medical Center, she began to appreciate the importance of quality issues for the field of hospital medicine.

Dr. Afsar, who recently was elected to the SHM board of directors, says, "I realized that evidence-based medicine should be the standard of care in hospitals, but we were nowhere near where we should be in addressing that at a systemic level."

Believing that her medical training had not fully prepared her for quality work, Dr. Afsar attended the Advanced Training Program at Intermountain Healthcare in Salt Lake City. "With that foundation, my focus ever since has been on improvement initiatives," she says.

In the years since, Dr. Afsar's quality responsibilities have grown steadily. She is now associate medical director of quality and safety at UCLA, executive director for quality and safety in its department of medicine, and director of quality for neurosurgery. That means about 80% of her work week is devoted to quality improvement (QI). And while her time seeing patients is less, she says the "clinical work is what inspires and motivates me, gives me my best ideas, and keeps me grounded."

Among the more than 40 quality and safety projects she has implemented at UCLA is "The ABCs of Hospitalized Patients," a multidisciplinary checklist designed to reduce the risk of eight common hospital-acquired conditions. "Within three weeks of implementing it, we started seeing significant improvement in every area, and we have been able to sustain that," she says. In 2009, she implemented a systemwide QI curriculum for the residents and fellows at UCLA.

Dr. Afsar, chair of SHM's Hospital Quality and Patient Safety Committee, says HM is challenged to make these kinds of quality approaches the standard of practice nationwide.

"Different institutions are doing different pieces of the quality movement very well," and SHM and its leaders on the board need to find a way to disseminate those best practices and integrate them into hospital practice, she says. "There are no simple ways to do that, but we know there are a lot of solutions out there."

Nearly five years ago, when Nasim Afsar, MD, SFHM, was launching her career as a hospitalist at the University of California Los Angeles Medical Center, she began to appreciate the importance of quality issues for the field of hospital medicine.

Dr. Afsar, who recently was elected to the SHM board of directors, says, "I realized that evidence-based medicine should be the standard of care in hospitals, but we were nowhere near where we should be in addressing that at a systemic level."

Believing that her medical training had not fully prepared her for quality work, Dr. Afsar attended the Advanced Training Program at Intermountain Healthcare in Salt Lake City. "With that foundation, my focus ever since has been on improvement initiatives," she says.

In the years since, Dr. Afsar's quality responsibilities have grown steadily. She is now associate medical director of quality and safety at UCLA, executive director for quality and safety in its department of medicine, and director of quality for neurosurgery. That means about 80% of her work week is devoted to quality improvement (QI). And while her time seeing patients is less, she says the "clinical work is what inspires and motivates me, gives me my best ideas, and keeps me grounded."

Among the more than 40 quality and safety projects she has implemented at UCLA is "The ABCs of Hospitalized Patients," a multidisciplinary checklist designed to reduce the risk of eight common hospital-acquired conditions. "Within three weeks of implementing it, we started seeing significant improvement in every area, and we have been able to sustain that," she says. In 2009, she implemented a systemwide QI curriculum for the residents and fellows at UCLA.

Dr. Afsar, chair of SHM's Hospital Quality and Patient Safety Committee, says HM is challenged to make these kinds of quality approaches the standard of practice nationwide.

"Different institutions are doing different pieces of the quality movement very well," and SHM and its leaders on the board need to find a way to disseminate those best practices and integrate them into hospital practice, she says. "There are no simple ways to do that, but we know there are a lot of solutions out there."

Hospitalist Ashish Jha, MD, MPH, doesn't want people to take his research on the value of pay-for-performance models the wrong way. Although a new study he worked on found no evidence that the Medicare Premier Hospital Quality Incentive Demonstration (HQID) led to decreased rates of 30-day mortality, he believes the program's structure—not its concept—is at issue.

"It's not that pay for performance doesn't work,” says Dr. Jha, associate professor of health policy and management at Harvard School of Public Health in Boston. "What we had in the HQID was pretty small incentives and mostly focused on processes of care, some of which are important, many of which are not. When you have that as your structure, it's not shocking to see in retrospect that it didn't have a big impact on outcomes."

The report, "The Long-Term Effect of Premier Pay for Performance on Patient Outcomes," showed that the composite 30-day mortality rates for patients with acute myocardial infarction, congestive heart failure, pneumonia, and coronary-artery bypass grafts were similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; 95% confidence interval, -0.40 to 0.26).

Dr. Jha says the results were surprising, but he believes that HQID, value-based purchasing, and any pay-for-performance model can only succeed if they more narrowly focus on outcomes. For example, he says, HQID should not have weighed reductions in 30-day mortality rates on par with providing smoking-cessation worksheets to patients at discharge.

"You need much stronger incentives," he says. If hospitals focus on outcomes—and, specifically, on the right outcomes—they will figure out what processes they need to engage in and refine, he says. "Hospitalists are going to be the key people there. If they know that their mortality rates are high, they're going to work on trying to figure out why."

Hospitalist Ashish Jha, MD, MPH, doesn't want people to take his research on the value of pay-for-performance models the wrong way. Although a new study he worked on found no evidence that the Medicare Premier Hospital Quality Incentive Demonstration (HQID) led to decreased rates of 30-day mortality, he believes the program's structure—not its concept—is at issue.

"It's not that pay for performance doesn't work,” says Dr. Jha, associate professor of health policy and management at Harvard School of Public Health in Boston. "What we had in the HQID was pretty small incentives and mostly focused on processes of care, some of which are important, many of which are not. When you have that as your structure, it's not shocking to see in retrospect that it didn't have a big impact on outcomes."

The report, "The Long-Term Effect of Premier Pay for Performance on Patient Outcomes," showed that the composite 30-day mortality rates for patients with acute myocardial infarction, congestive heart failure, pneumonia, and coronary-artery bypass grafts were similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; 95% confidence interval, -0.40 to 0.26).

Dr. Jha says the results were surprising, but he believes that HQID, value-based purchasing, and any pay-for-performance model can only succeed if they more narrowly focus on outcomes. For example, he says, HQID should not have weighed reductions in 30-day mortality rates on par with providing smoking-cessation worksheets to patients at discharge.

"You need much stronger incentives," he says. If hospitals focus on outcomes—and, specifically, on the right outcomes—they will figure out what processes they need to engage in and refine, he says. "Hospitalists are going to be the key people there. If they know that their mortality rates are high, they're going to work on trying to figure out why."

Hospitalist Ashish Jha, MD, MPH, doesn't want people to take his research on the value of pay-for-performance models the wrong way. Although a new study he worked on found no evidence that the Medicare Premier Hospital Quality Incentive Demonstration (HQID) led to decreased rates of 30-day mortality, he believes the program's structure—not its concept—is at issue.

"It's not that pay for performance doesn't work,” says Dr. Jha, associate professor of health policy and management at Harvard School of Public Health in Boston. "What we had in the HQID was pretty small incentives and mostly focused on processes of care, some of which are important, many of which are not. When you have that as your structure, it's not shocking to see in retrospect that it didn't have a big impact on outcomes."

The report, "The Long-Term Effect of Premier Pay for Performance on Patient Outcomes," showed that the composite 30-day mortality rates for patients with acute myocardial infarction, congestive heart failure, pneumonia, and coronary-artery bypass grafts were similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; 95% confidence interval, -0.40 to 0.26).

Dr. Jha says the results were surprising, but he believes that HQID, value-based purchasing, and any pay-for-performance model can only succeed if they more narrowly focus on outcomes. For example, he says, HQID should not have weighed reductions in 30-day mortality rates on par with providing smoking-cessation worksheets to patients at discharge.

"You need much stronger incentives," he says. If hospitals focus on outcomes—and, specifically, on the right outcomes—they will figure out what processes they need to engage in and refine, he says. "Hospitalists are going to be the key people there. If they know that their mortality rates are high, they're going to work on trying to figure out why."