Editorial

Hospitalists have become well versed in campaigns championing safe, efficient, and timely discharges, as well as in the pragmatic challenges of achieving them. Successfully discharging a patient from the hospital requires synchronizing several elements; as a result, improvement efforts focus on promoting shared mental models and team identification of early discharges. The urgency for timely discharges, much like (and unlike¹) hotel check-out times, becomes increasingly relevant when hospitals are functioning at or beyond full capacity. As inpatient medical care grows increasingly more specialized, promoting high-quality discharges theoretically allows for not only more beds, but also that the right bed is available for the right patient at the right time. In addition, financial realities in terms of reimbursement and the high cost of adding capacity imply that hospitals need to maximize throughput from the beds they already have. For these reasons, hospital administrators and operational leaders have focused on early discharges as a goal—and have often used discharge before noon (DCBN) as the metric to measure performance.

In this issue of the Journal of Hospital Medicine, Destino et al. reported that it is possible to achieve a higher percentage of early discharges, which allowed for decompression of post-anesthesia care and emergency areas without a measurable negative impact on patient or family satisfaction or length of stay (LOS).² The improvement they report is remarkable. However, it will be important for them to report back, as quality improvement projects often revert to prior state unless the processes are reinforced and embedded in hospital culture. In addition, what goes unreported in Destino et al. are the unmeasured and unanticipated outcomes related to focusing on a single, laudable goal. This study and others have yet to confirm that systems have enough resiliency to improve discharge timeliness without diverting resources from other aspects of care.³ In other words, can inpatient teams do everything at the same time without sacrificing quality; ie, improve discharge timeliness, accept and admit new patients faster, respond to deteriorating patients, spend enough time with patients and families to meet their needs (and validated survey expectations), and in educational settings, meet the learning needs of trainees?⁴ This may prove to be true if implementation techniques are individualized to hospitals, services, and units and are incorporated into existing workflows, minimizing extraneous “asks” on already overtaxed providers. Evidence to support this would go a long way in engaging stakeholders to prioritize quality discharges.

In this issue, too, James, et al. ask the question “if DCBN is a good indicator of shorter LOS or is DCBN an arbitrary indicator.”⁵ The answer may be yes, no, both, maybe, and it depends. Certainly, no pathophysiological reasons exist for a certain time of day to be the “right” time for discharge. The key question for hospitalists and health systems leaders is whether setting time goals leads clinicians to delay discharges of medically and logistically ready patients in the afternoon or evening, particularly if the metric is linked to monetary performance incentives. This is also likely a matter of degrees, ie, set the DCBN goal at 80%-100% and gaming is much more likely; set the goal at 20%-30% and this might reflect a realistic range and be less likely to incentivize gaming. Notably, the hospital in the James study did not have a DCBN goal. It would be interesting to see what would happen in that hospital or another hospital before and after implementing a DCBN goal—and further assess a dose-response curve. Another approach would be to perform qualitative analysis of readiness for discharge via chart reviews and determine if patients could have left in the afternoon or evening but might have been delayed to buff up the performance on the DCBN metric.

James et al. additionally demonstrate differences for medical and surgical patients, underscoring that a DCBN goal is unlikely to yield the same results in different patient cohorts or settings. The authors note several workflow reasons for this variation, but other considerations are regularity of timelines for recovery being different for surgical patients, role of elective admissions scheduled in advance, and the potential use of conditional orders (ie, orders entered before dawn that nurses can activate as patients meet criteria).

What both studies highlight is that although morning discharges can help with patient flow, hospitalists and hospital leaders need to be mindful and seek more information before implementing DCBN programs. One strategy that can promote efficient discharge regardless of the position of the sun in the sky, account for variation in patient populations and individual patients, and mitigate the potential for gaming the system is to strive toward measuring time from medical readiness to the time of discharge. Although some institutions have had success with this work,⁶ it remains challenging to implement this across all patient populations. Criteria for medical readiness need to be agreed upon and validated, and then a real-time way of identifying when criteria are met needs to be developed. In this regard, hospitals may have to invest individually or collectively to build such systems, but the benefit would be to enable and promote performance of timely discharge for all patients at all times of day.

Much as we have adopted cultural changes over the years to raise awareness regarding patient safety such as nosocomial infections and hand hygiene, an emphasis on high-quality discharges too needs to become integral to hospital practices to sustain performance and any associated metrics. As to what to measure? A validated “medical readiness to discharge” may be the gold standard but may be difficult to attain. Until then, carefully constructed approaches to prioritizing early discharges through proactive planning, shared mental models, interdisciplinary teamwork, and appropriate incentives to those who do it well could yield the results we want as hospitalists, as patients, and as families.

Disclosures

Dr. Kane and Dr. Fieldston have nothing to disclose.

Hospitalists have become well versed in campaigns championing safe, efficient, and timely discharges, as well as in the pragmatic challenges of achieving them. Successfully discharging a patient from the hospital requires synchronizing several elements; as a result, improvement efforts focus on promoting shared mental models and team identification of early discharges. The urgency for timely discharges, much like (and unlike¹) hotel check-out times, becomes increasingly relevant when hospitals are functioning at or beyond full capacity. As inpatient medical care grows increasingly more specialized, promoting high-quality discharges theoretically allows for not only more beds, but also that the right bed is available for the right patient at the right time. In addition, financial realities in terms of reimbursement and the high cost of adding capacity imply that hospitals need to maximize throughput from the beds they already have. For these reasons, hospital administrators and operational leaders have focused on early discharges as a goal—and have often used discharge before noon (DCBN) as the metric to measure performance.

In this issue of the Journal of Hospital Medicine, Destino et al. reported that it is possible to achieve a higher percentage of early discharges, which allowed for decompression of post-anesthesia care and emergency areas without a measurable negative impact on patient or family satisfaction or length of stay (LOS).² The improvement they report is remarkable. However, it will be important for them to report back, as quality improvement projects often revert to prior state unless the processes are reinforced and embedded in hospital culture. In addition, what goes unreported in Destino et al. are the unmeasured and unanticipated outcomes related to focusing on a single, laudable goal. This study and others have yet to confirm that systems have enough resiliency to improve discharge timeliness without diverting resources from other aspects of care.³ In other words, can inpatient teams do everything at the same time without sacrificing quality; ie, improve discharge timeliness, accept and admit new patients faster, respond to deteriorating patients, spend enough time with patients and families to meet their needs (and validated survey expectations), and in educational settings, meet the learning needs of trainees?⁴ This may prove to be true if implementation techniques are individualized to hospitals, services, and units and are incorporated into existing workflows, minimizing extraneous “asks” on already overtaxed providers. Evidence to support this would go a long way in engaging stakeholders to prioritize quality discharges.

In this issue, too, James, et al. ask the question “if DCBN is a good indicator of shorter LOS or is DCBN an arbitrary indicator.”⁵ The answer may be yes, no, both, maybe, and it depends. Certainly, no pathophysiological reasons exist for a certain time of day to be the “right” time for discharge. The key question for hospitalists and health systems leaders is whether setting time goals leads clinicians to delay discharges of medically and logistically ready patients in the afternoon or evening, particularly if the metric is linked to monetary performance incentives. This is also likely a matter of degrees, ie, set the DCBN goal at 80%-100% and gaming is much more likely; set the goal at 20%-30% and this might reflect a realistic range and be less likely to incentivize gaming. Notably, the hospital in the James study did not have a DCBN goal. It would be interesting to see what would happen in that hospital or another hospital before and after implementing a DCBN goal—and further assess a dose-response curve. Another approach would be to perform qualitative analysis of readiness for discharge via chart reviews and determine if patients could have left in the afternoon or evening but might have been delayed to buff up the performance on the DCBN metric.

James et al. additionally demonstrate differences for medical and surgical patients, underscoring that a DCBN goal is unlikely to yield the same results in different patient cohorts or settings. The authors note several workflow reasons for this variation, but other considerations are regularity of timelines for recovery being different for surgical patients, role of elective admissions scheduled in advance, and the potential use of conditional orders (ie, orders entered before dawn that nurses can activate as patients meet criteria).

What both studies highlight is that although morning discharges can help with patient flow, hospitalists and hospital leaders need to be mindful and seek more information before implementing DCBN programs. One strategy that can promote efficient discharge regardless of the position of the sun in the sky, account for variation in patient populations and individual patients, and mitigate the potential for gaming the system is to strive toward measuring time from medical readiness to the time of discharge. Although some institutions have had success with this work,⁶ it remains challenging to implement this across all patient populations. Criteria for medical readiness need to be agreed upon and validated, and then a real-time way of identifying when criteria are met needs to be developed. In this regard, hospitals may have to invest individually or collectively to build such systems, but the benefit would be to enable and promote performance of timely discharge for all patients at all times of day.

Much as we have adopted cultural changes over the years to raise awareness regarding patient safety such as nosocomial infections and hand hygiene, an emphasis on high-quality discharges too needs to become integral to hospital practices to sustain performance and any associated metrics. As to what to measure? A validated “medical readiness to discharge” may be the gold standard but may be difficult to attain. Until then, carefully constructed approaches to prioritizing early discharges through proactive planning, shared mental models, interdisciplinary teamwork, and appropriate incentives to those who do it well could yield the results we want as hospitalists, as patients, and as families.

Disclosures

Dr. Kane and Dr. Fieldston have nothing to disclose.

Hospitalists have become well versed in campaigns championing safe, efficient, and timely discharges, as well as in the pragmatic challenges of achieving them. Successfully discharging a patient from the hospital requires synchronizing several elements; as a result, improvement efforts focus on promoting shared mental models and team identification of early discharges. The urgency for timely discharges, much like (and unlike¹) hotel check-out times, becomes increasingly relevant when hospitals are functioning at or beyond full capacity. As inpatient medical care grows increasingly more specialized, promoting high-quality discharges theoretically allows for not only more beds, but also that the right bed is available for the right patient at the right time. In addition, financial realities in terms of reimbursement and the high cost of adding capacity imply that hospitals need to maximize throughput from the beds they already have. For these reasons, hospital administrators and operational leaders have focused on early discharges as a goal—and have often used discharge before noon (DCBN) as the metric to measure performance.

In this issue of the Journal of Hospital Medicine, Destino et al. reported that it is possible to achieve a higher percentage of early discharges, which allowed for decompression of post-anesthesia care and emergency areas without a measurable negative impact on patient or family satisfaction or length of stay (LOS).² The improvement they report is remarkable. However, it will be important for them to report back, as quality improvement projects often revert to prior state unless the processes are reinforced and embedded in hospital culture. In addition, what goes unreported in Destino et al. are the unmeasured and unanticipated outcomes related to focusing on a single, laudable goal. This study and others have yet to confirm that systems have enough resiliency to improve discharge timeliness without diverting resources from other aspects of care.³ In other words, can inpatient teams do everything at the same time without sacrificing quality; ie, improve discharge timeliness, accept and admit new patients faster, respond to deteriorating patients, spend enough time with patients and families to meet their needs (and validated survey expectations), and in educational settings, meet the learning needs of trainees?⁴ This may prove to be true if implementation techniques are individualized to hospitals, services, and units and are incorporated into existing workflows, minimizing extraneous “asks” on already overtaxed providers. Evidence to support this would go a long way in engaging stakeholders to prioritize quality discharges.

In this issue, too, James, et al. ask the question “if DCBN is a good indicator of shorter LOS or is DCBN an arbitrary indicator.”⁵ The answer may be yes, no, both, maybe, and it depends. Certainly, no pathophysiological reasons exist for a certain time of day to be the “right” time for discharge. The key question for hospitalists and health systems leaders is whether setting time goals leads clinicians to delay discharges of medically and logistically ready patients in the afternoon or evening, particularly if the metric is linked to monetary performance incentives. This is also likely a matter of degrees, ie, set the DCBN goal at 80%-100% and gaming is much more likely; set the goal at 20%-30% and this might reflect a realistic range and be less likely to incentivize gaming. Notably, the hospital in the James study did not have a DCBN goal. It would be interesting to see what would happen in that hospital or another hospital before and after implementing a DCBN goal—and further assess a dose-response curve. Another approach would be to perform qualitative analysis of readiness for discharge via chart reviews and determine if patients could have left in the afternoon or evening but might have been delayed to buff up the performance on the DCBN metric.

James et al. additionally demonstrate differences for medical and surgical patients, underscoring that a DCBN goal is unlikely to yield the same results in different patient cohorts or settings. The authors note several workflow reasons for this variation, but other considerations are regularity of timelines for recovery being different for surgical patients, role of elective admissions scheduled in advance, and the potential use of conditional orders (ie, orders entered before dawn that nurses can activate as patients meet criteria).

What both studies highlight is that although morning discharges can help with patient flow, hospitalists and hospital leaders need to be mindful and seek more information before implementing DCBN programs. One strategy that can promote efficient discharge regardless of the position of the sun in the sky, account for variation in patient populations and individual patients, and mitigate the potential for gaming the system is to strive toward measuring time from medical readiness to the time of discharge. Although some institutions have had success with this work,⁶ it remains challenging to implement this across all patient populations. Criteria for medical readiness need to be agreed upon and validated, and then a real-time way of identifying when criteria are met needs to be developed. In this regard, hospitals may have to invest individually or collectively to build such systems, but the benefit would be to enable and promote performance of timely discharge for all patients at all times of day.

Much as we have adopted cultural changes over the years to raise awareness regarding patient safety such as nosocomial infections and hand hygiene, an emphasis on high-quality discharges too needs to become integral to hospital practices to sustain performance and any associated metrics. As to what to measure? A validated “medical readiness to discharge” may be the gold standard but may be difficult to attain. Until then, carefully constructed approaches to prioritizing early discharges through proactive planning, shared mental models, interdisciplinary teamwork, and appropriate incentives to those who do it well could yield the results we want as hospitalists, as patients, and as families.

Disclosures

Dr. Kane and Dr. Fieldston have nothing to disclose.

It is 5:45 am. Thousands of diligent interns are roaming inpatient wards, quietly entering hospital rooms, and gently nudging their patients awake. Little do they know that their rounding is part of a system that unintentionally degrades the quantity and quality of patient sleep and may leave patients worse off than the illness that originally brought them to the hospital.¹ A multitude of adverse outcomes has been associated with sleep deprivation, including aberrant glucose metabolism, impaired wound healing, impaired physical function and coordination, and altered cognition.² To put it simply, sleep is vital.³ Restoring normal sleep patterns in hospitalized patients may decrease hospital length of stay, reduce hospital readmissions, and, as such, should be a new priority for quality improvement.⁴

In this edition of the Journal of Hospital Medicine, Arora et al. present a single-center, pre–post analysis of an intervention designed to improve sleep for hospitalized patients.⁵ The SIESTA (Sleep for Inpatients: Empowering Staff to Act) intervention was composed of the following three components: provider education on patient sleep, Electronic Health Record (EHR) promotion of sleep-friendly order entry, and empowerment of nurses to actively protect patient sleep. Education and changes to order entry were implemented in two hospital units, but only one received the additional nurse-empowerment intervention. Results were compared for six months pre- and post-intervention. Although the authors found increases in sleep-friendly orders in both units, nighttime room entries and patient-reported sleep disturbance decreased only in the nurse-empowerment unit.

Previous studies assessing both pharmacologic sleep aids as well as bundled nonpharmacologic interventions have demonstrated mixed results and focused primarily on ICU populations.^6,7 What sets this study apart from prior interventions aimed at improving patient sleep is the novelty and implications of their successful intervention. In this study, the authors used the EHR and nursing huddles to “nudge” providers to protect their patients’ sleep. The “nudge” concept, first studied in behavioral economics and more recently applied to healthcare, represents ways to present choices that positively influence behavior without restricting options.⁸ This study incorporates two distinct nudges, one that utilized the EMR to adjust the default timing of orders for vital sign procurement and delivery of VTE-prophylaxis, and another that made sleep part of the default checklist for nursing huddles. This study suggests that nudges altered both physician and nurse behavior and encouraged improvements in process measures, if not clinical outcomes, around patient sleep.

A key insight and strength of this study was to engage and empower nurses to promote better sleep for patients. In particular, nurses in the sleep-enhanced unit suggested—during the course of the intervention—that sleep protection be added as a default item in daily huddles. As illustrated in the Figure, the timing of this suggestion corresponded with an inflection point in reducing patient room disruptions at night. This simple, low-cost nudge sustained sleep improvement while the effect of the initial higher-cost intervention using pocket cards and posters had begun to fade. This is not a randomized clinical trial, but rather a pragmatic assessment of a rigorous quality improvement initiative. Although more follow-up time, particularly after the nurse-empowerment intervention was adjusted, would be helpful to assess the durability of their intervention, we applaud the authors for demonstrating adaptability and efforts for ongoing engagement, as is needed in real-world quality improvement initiatives.

There are additional factors that disrupt patient sleep that were not targeted in this study but could very well respond to nudges. Recently, Wesselius et al. showed that patient-reported nocturnal awakenings were frequently due to toilet visits and awakening by hospital staff.⁹ Perhaps nudges could be implemented to reduce unnecessary overnight intravenous fluids, prevent late dosing of diuretics, and delay the default timing of standard morning phlebotomy orders.

Although this study by Arora et al. makes a very meaningful contribution to the literature on sleep and hospitalization, it also raises unanswered questions.⁵ First and foremost, while the pragmatic nature of this study should inspire other hospitals to attempt similar sleep promotion interventions, the use of a pre–post design (rather than a randomized, control design) leaves room for future studies to explore causality more rigorously. Second, although this study has demonstrated significant uptake in standardized order sets to improve sleep (and a corresponding decrease in patient-reported disruptions), future studies should also explore more distal and more challenging outcomes of care. These could include length of stay, incidence of delirium (especially in older adults), and frequency of readmission after discharge. Finally, more longitudinal data to explore the sustainability of order set usage and reported or observed interruptions would be useful to guide hospitals that would like to follow the example set by the SIESTA study.

Notwithstanding these limitations, there is an incredible opportunity for nudges and technology to combine to change the paradigms of clinical care. One of the outcomes of this study was to reduce nocturnal room entry for clinical tasks such as obtaining vital signs. It is worth considering whether providers even need to enter patient rooms to obtain vital signs. The technology now exists to measure vitals passively and continuously via low-impact wearable devices. Milani et al. employed the use of such devices, as well as other techniques, including red-enriched light and sensors that warned staff in clinical areas when noises exceeded acceptable thresholds for sleep, and demonstrated decreases in hospital length of stay and readmission rates.⁴

Arora et al. present a compelling study of utilizing nudges to influence physician and nurse behavior.⁵ They show that rigorous quality improvement initiatives can be studied and disseminated in a compelling manner. Their study calls appropriate attention to the need for improving patient sleep and provides us with additional tools that can be used in these efforts. Future research is needed to determine whether the changes observed in process measures will translate into meaningful effects on clinical outcomes and to continue to identify ways to curb some of the toxicities of hospital care.

Disclosures

The authors have nothing to disclose.

It is 5:45 am. Thousands of diligent interns are roaming inpatient wards, quietly entering hospital rooms, and gently nudging their patients awake. Little do they know that their rounding is part of a system that unintentionally degrades the quantity and quality of patient sleep and may leave patients worse off than the illness that originally brought them to the hospital.¹ A multitude of adverse outcomes has been associated with sleep deprivation, including aberrant glucose metabolism, impaired wound healing, impaired physical function and coordination, and altered cognition.² To put it simply, sleep is vital.³ Restoring normal sleep patterns in hospitalized patients may decrease hospital length of stay, reduce hospital readmissions, and, as such, should be a new priority for quality improvement.⁴

In this edition of the Journal of Hospital Medicine, Arora et al. present a single-center, pre–post analysis of an intervention designed to improve sleep for hospitalized patients.⁵ The SIESTA (Sleep for Inpatients: Empowering Staff to Act) intervention was composed of the following three components: provider education on patient sleep, Electronic Health Record (EHR) promotion of sleep-friendly order entry, and empowerment of nurses to actively protect patient sleep. Education and changes to order entry were implemented in two hospital units, but only one received the additional nurse-empowerment intervention. Results were compared for six months pre- and post-intervention. Although the authors found increases in sleep-friendly orders in both units, nighttime room entries and patient-reported sleep disturbance decreased only in the nurse-empowerment unit.

Previous studies assessing both pharmacologic sleep aids as well as bundled nonpharmacologic interventions have demonstrated mixed results and focused primarily on ICU populations.^6,7 What sets this study apart from prior interventions aimed at improving patient sleep is the novelty and implications of their successful intervention. In this study, the authors used the EHR and nursing huddles to “nudge” providers to protect their patients’ sleep. The “nudge” concept, first studied in behavioral economics and more recently applied to healthcare, represents ways to present choices that positively influence behavior without restricting options.⁸ This study incorporates two distinct nudges, one that utilized the EMR to adjust the default timing of orders for vital sign procurement and delivery of VTE-prophylaxis, and another that made sleep part of the default checklist for nursing huddles. This study suggests that nudges altered both physician and nurse behavior and encouraged improvements in process measures, if not clinical outcomes, around patient sleep.

A key insight and strength of this study was to engage and empower nurses to promote better sleep for patients. In particular, nurses in the sleep-enhanced unit suggested—during the course of the intervention—that sleep protection be added as a default item in daily huddles. As illustrated in the Figure, the timing of this suggestion corresponded with an inflection point in reducing patient room disruptions at night. This simple, low-cost nudge sustained sleep improvement while the effect of the initial higher-cost intervention using pocket cards and posters had begun to fade. This is not a randomized clinical trial, but rather a pragmatic assessment of a rigorous quality improvement initiative. Although more follow-up time, particularly after the nurse-empowerment intervention was adjusted, would be helpful to assess the durability of their intervention, we applaud the authors for demonstrating adaptability and efforts for ongoing engagement, as is needed in real-world quality improvement initiatives.

There are additional factors that disrupt patient sleep that were not targeted in this study but could very well respond to nudges. Recently, Wesselius et al. showed that patient-reported nocturnal awakenings were frequently due to toilet visits and awakening by hospital staff.⁹ Perhaps nudges could be implemented to reduce unnecessary overnight intravenous fluids, prevent late dosing of diuretics, and delay the default timing of standard morning phlebotomy orders.

Although this study by Arora et al. makes a very meaningful contribution to the literature on sleep and hospitalization, it also raises unanswered questions.⁵ First and foremost, while the pragmatic nature of this study should inspire other hospitals to attempt similar sleep promotion interventions, the use of a pre–post design (rather than a randomized, control design) leaves room for future studies to explore causality more rigorously. Second, although this study has demonstrated significant uptake in standardized order sets to improve sleep (and a corresponding decrease in patient-reported disruptions), future studies should also explore more distal and more challenging outcomes of care. These could include length of stay, incidence of delirium (especially in older adults), and frequency of readmission after discharge. Finally, more longitudinal data to explore the sustainability of order set usage and reported or observed interruptions would be useful to guide hospitals that would like to follow the example set by the SIESTA study.

Notwithstanding these limitations, there is an incredible opportunity for nudges and technology to combine to change the paradigms of clinical care. One of the outcomes of this study was to reduce nocturnal room entry for clinical tasks such as obtaining vital signs. It is worth considering whether providers even need to enter patient rooms to obtain vital signs. The technology now exists to measure vitals passively and continuously via low-impact wearable devices. Milani et al. employed the use of such devices, as well as other techniques, including red-enriched light and sensors that warned staff in clinical areas when noises exceeded acceptable thresholds for sleep, and demonstrated decreases in hospital length of stay and readmission rates.⁴

Arora et al. present a compelling study of utilizing nudges to influence physician and nurse behavior.⁵ They show that rigorous quality improvement initiatives can be studied and disseminated in a compelling manner. Their study calls appropriate attention to the need for improving patient sleep and provides us with additional tools that can be used in these efforts. Future research is needed to determine whether the changes observed in process measures will translate into meaningful effects on clinical outcomes and to continue to identify ways to curb some of the toxicities of hospital care.

Disclosures

The authors have nothing to disclose.

It is 5:45 am. Thousands of diligent interns are roaming inpatient wards, quietly entering hospital rooms, and gently nudging their patients awake. Little do they know that their rounding is part of a system that unintentionally degrades the quantity and quality of patient sleep and may leave patients worse off than the illness that originally brought them to the hospital.¹ A multitude of adverse outcomes has been associated with sleep deprivation, including aberrant glucose metabolism, impaired wound healing, impaired physical function and coordination, and altered cognition.² To put it simply, sleep is vital.³ Restoring normal sleep patterns in hospitalized patients may decrease hospital length of stay, reduce hospital readmissions, and, as such, should be a new priority for quality improvement.⁴

In this edition of the Journal of Hospital Medicine, Arora et al. present a single-center, pre–post analysis of an intervention designed to improve sleep for hospitalized patients.⁵ The SIESTA (Sleep for Inpatients: Empowering Staff to Act) intervention was composed of the following three components: provider education on patient sleep, Electronic Health Record (EHR) promotion of sleep-friendly order entry, and empowerment of nurses to actively protect patient sleep. Education and changes to order entry were implemented in two hospital units, but only one received the additional nurse-empowerment intervention. Results were compared for six months pre- and post-intervention. Although the authors found increases in sleep-friendly orders in both units, nighttime room entries and patient-reported sleep disturbance decreased only in the nurse-empowerment unit.

Previous studies assessing both pharmacologic sleep aids as well as bundled nonpharmacologic interventions have demonstrated mixed results and focused primarily on ICU populations.^6,7 What sets this study apart from prior interventions aimed at improving patient sleep is the novelty and implications of their successful intervention. In this study, the authors used the EHR and nursing huddles to “nudge” providers to protect their patients’ sleep. The “nudge” concept, first studied in behavioral economics and more recently applied to healthcare, represents ways to present choices that positively influence behavior without restricting options.⁸ This study incorporates two distinct nudges, one that utilized the EMR to adjust the default timing of orders for vital sign procurement and delivery of VTE-prophylaxis, and another that made sleep part of the default checklist for nursing huddles. This study suggests that nudges altered both physician and nurse behavior and encouraged improvements in process measures, if not clinical outcomes, around patient sleep.

A key insight and strength of this study was to engage and empower nurses to promote better sleep for patients. In particular, nurses in the sleep-enhanced unit suggested—during the course of the intervention—that sleep protection be added as a default item in daily huddles. As illustrated in the Figure, the timing of this suggestion corresponded with an inflection point in reducing patient room disruptions at night. This simple, low-cost nudge sustained sleep improvement while the effect of the initial higher-cost intervention using pocket cards and posters had begun to fade. This is not a randomized clinical trial, but rather a pragmatic assessment of a rigorous quality improvement initiative. Although more follow-up time, particularly after the nurse-empowerment intervention was adjusted, would be helpful to assess the durability of their intervention, we applaud the authors for demonstrating adaptability and efforts for ongoing engagement, as is needed in real-world quality improvement initiatives.

There are additional factors that disrupt patient sleep that were not targeted in this study but could very well respond to nudges. Recently, Wesselius et al. showed that patient-reported nocturnal awakenings were frequently due to toilet visits and awakening by hospital staff.⁹ Perhaps nudges could be implemented to reduce unnecessary overnight intravenous fluids, prevent late dosing of diuretics, and delay the default timing of standard morning phlebotomy orders.

Although this study by Arora et al. makes a very meaningful contribution to the literature on sleep and hospitalization, it also raises unanswered questions.⁵ First and foremost, while the pragmatic nature of this study should inspire other hospitals to attempt similar sleep promotion interventions, the use of a pre–post design (rather than a randomized, control design) leaves room for future studies to explore causality more rigorously. Second, although this study has demonstrated significant uptake in standardized order sets to improve sleep (and a corresponding decrease in patient-reported disruptions), future studies should also explore more distal and more challenging outcomes of care. These could include length of stay, incidence of delirium (especially in older adults), and frequency of readmission after discharge. Finally, more longitudinal data to explore the sustainability of order set usage and reported or observed interruptions would be useful to guide hospitals that would like to follow the example set by the SIESTA study.

Notwithstanding these limitations, there is an incredible opportunity for nudges and technology to combine to change the paradigms of clinical care. One of the outcomes of this study was to reduce nocturnal room entry for clinical tasks such as obtaining vital signs. It is worth considering whether providers even need to enter patient rooms to obtain vital signs. The technology now exists to measure vitals passively and continuously via low-impact wearable devices. Milani et al. employed the use of such devices, as well as other techniques, including red-enriched light and sensors that warned staff in clinical areas when noises exceeded acceptable thresholds for sleep, and demonstrated decreases in hospital length of stay and readmission rates.⁴

Arora et al. present a compelling study of utilizing nudges to influence physician and nurse behavior.⁵ They show that rigorous quality improvement initiatives can be studied and disseminated in a compelling manner. Their study calls appropriate attention to the need for improving patient sleep and provides us with additional tools that can be used in these efforts. Future research is needed to determine whether the changes observed in process measures will translate into meaningful effects on clinical outcomes and to continue to identify ways to curb some of the toxicities of hospital care.

Disclosures

The authors have nothing to disclose.

Whenever the principles of effective medical consultation are discussed, a classic article published in 1983 by Lee Goldman et al. is invariably referenced. In the “Ten Commandments for Effective Consultation,” Goldman argued that internists should “determine the question, establish urgency, look for yourself, be as brief as appropriate, be specific, provide contingency plans, honor thy turf, teach with tact, provide direct personal contact, and follow up.”¹ If these Ten Commandments were followed, then the consultation would be more effective and satisfactory for both the consultant and the referring provider. However, with the advent of comanagement in 1994 where internists and surgeons have a “shared responsibility and accountability,”² there has been a shift, and the once-concrete definitions of a specific reason for consult and the nature of “turf” have become blurred. Since 1994, the use of medical consultation and comanagement has skyrocketed, and today, more than 50% of surgical patients have a medical consultation or comanagement.³ This may be due to increased time pressures on surgeons and better outcomes of comanaged patients (eg, fewer postoperative complications, fewer transfers to an intensive care unit for acute medical deterioration, and increased likelihood to discharge to home).⁴

Medical management of surgical patients in the hospital involves a different skill set than that required to manage general medical patients. Accordingly, in 2012, the Accreditation Council for Graduate Medical Education (ACGME) made medical consultation and perioperative care an End of Training Entrustable Professional Activities and ACGME subcompetency. Earlier this year, a nationwide perioperative curriculum for graduate medical education was consisting of eight objective and core topic modules and pretest/posttest questions selected from SHMConsults.com, including assessment and management of perioperative cardiac and pulmonary risk and management of diabetes, perioperative fever, and anticoagulants. Trainees were assessed using the multiple-choice questions, observed mini-cex, and written evaluation of a consultation report. Despite this encouraging development of curricula and competencies for trainees, there are still important gaps in our knowledge of basic patterns for consultation practices. For example, the type of patients and medical conditions currently encountered on our medical consultation and comanagement services had been previously unknown.

In the December issue of the Journal of Hospital Medicine, Wang et al. answer this question through the first cross-sectional multicenter prospective survey to examine medical consultation/comanagement practices since observational studies in the 1970-1990s.⁶ In a sample of 1,264 consultation requests from 11 academic medical centers over four two-week periods from July 2014 through July 2015, they found that the most common requests for consultation were medical management/comanagement, preoperative evaluation, blood pressure management, and other common postoperative complications, including postoperative atrial fibrillation, heart failure, renal failure, hyponatremia, anemia, hypoxia, and altered mental status.⁹ The majority of referrals were from orthopedic surgery and neurosurgery. They also found that medical consultants and comanagers provided comprehensive evaluations where more than a third of encounters addressed issues that were not stated in the initial reason for consult (RFC) and that consultants addressed more than two RFCs per encounter.⁹

These findings illustrate the paradigm shift of medical consultation focusing on a single specific question to addressing and optimizing the entire patient. This shift toward a broader, more open-ended reason for consultation may present some challenges such as “dumping” where referring surgeons and other specialists signoff their patients after surgery is completed, with internists processing the surgeons’ patients through the hospitalization. These challenges can be mitigated with predefined comanagement agreements with clearly defined roles and collaborative professional relationships.

Nonetheless, given the recent developments in curricula and training competencies mentioned above, internists are better equipped than ever before to put everything together and take care of the medical conditions of the increasingly complex and older surgical patient. For example, if one is consulted to see a patient for postoperative hypertension, it is difficult to not address the patient’s blood sugars in the 300s, lack of venous thromboembolism prophylaxis, delirium, acute renal failure, and acute blood loss anemia. The authors are correct to assert it is critically important to ensure that this input is desired by the referring physician either via verbal communication or comanagement agreements.

The findings of Wang et al. suggest some important future steps in medical consultation to ensure that our trainees and colleagues are prepared to take care of the entire patient regardless of whether the patient is on a consultant or comanagement agreement. This study shows that trainees are exposed to a diverse clinical experience on our medical consultation and comanagement services, which is in accordance with the objectives, assessment tools, and modules of the nationwide curriculum. It is likely that comanagement services will continue to expand as more of our medically complex patients will need either elective or emergency surgeries and surgeons have become less comfortable managing these patients on their own. We also may be asked to participate in quality improvement initiatives in the management of surgical patients, including the “perioperative surgical home programs,” where physicians work on a patient-centered approach to the surgical patient using evidence-based standard clinical care pathways and transitions from before surgery to postdischarge.⁷ We should share our experiences in quality improvement and the patient-centered medical home to ensure that our patients are optimized for surgery and beyond. As Lee Goldman et al. stated in the “Ten Commandments for Effective Consultations,¹” consultative medicine is an important part of an internal medicine practice. Today, more than ever, the consultant or comanagement role or roles need to be carefully defined and clear communication and follow-up are important.

Whenever the principles of effective medical consultation are discussed, a classic article published in 1983 by Lee Goldman et al. is invariably referenced. In the “Ten Commandments for Effective Consultation,” Goldman argued that internists should “determine the question, establish urgency, look for yourself, be as brief as appropriate, be specific, provide contingency plans, honor thy turf, teach with tact, provide direct personal contact, and follow up.”¹ If these Ten Commandments were followed, then the consultation would be more effective and satisfactory for both the consultant and the referring provider. However, with the advent of comanagement in 1994 where internists and surgeons have a “shared responsibility and accountability,”² there has been a shift, and the once-concrete definitions of a specific reason for consult and the nature of “turf” have become blurred. Since 1994, the use of medical consultation and comanagement has skyrocketed, and today, more than 50% of surgical patients have a medical consultation or comanagement.³ This may be due to increased time pressures on surgeons and better outcomes of comanaged patients (eg, fewer postoperative complications, fewer transfers to an intensive care unit for acute medical deterioration, and increased likelihood to discharge to home).⁴

Medical management of surgical patients in the hospital involves a different skill set than that required to manage general medical patients. Accordingly, in 2012, the Accreditation Council for Graduate Medical Education (ACGME) made medical consultation and perioperative care an End of Training Entrustable Professional Activities and ACGME subcompetency. Earlier this year, a nationwide perioperative curriculum for graduate medical education was consisting of eight objective and core topic modules and pretest/posttest questions selected from SHMConsults.com, including assessment and management of perioperative cardiac and pulmonary risk and management of diabetes, perioperative fever, and anticoagulants. Trainees were assessed using the multiple-choice questions, observed mini-cex, and written evaluation of a consultation report. Despite this encouraging development of curricula and competencies for trainees, there are still important gaps in our knowledge of basic patterns for consultation practices. For example, the type of patients and medical conditions currently encountered on our medical consultation and comanagement services had been previously unknown.

In the December issue of the Journal of Hospital Medicine, Wang et al. answer this question through the first cross-sectional multicenter prospective survey to examine medical consultation/comanagement practices since observational studies in the 1970-1990s.⁶ In a sample of 1,264 consultation requests from 11 academic medical centers over four two-week periods from July 2014 through July 2015, they found that the most common requests for consultation were medical management/comanagement, preoperative evaluation, blood pressure management, and other common postoperative complications, including postoperative atrial fibrillation, heart failure, renal failure, hyponatremia, anemia, hypoxia, and altered mental status.⁹ The majority of referrals were from orthopedic surgery and neurosurgery. They also found that medical consultants and comanagers provided comprehensive evaluations where more than a third of encounters addressed issues that were not stated in the initial reason for consult (RFC) and that consultants addressed more than two RFCs per encounter.⁹

These findings illustrate the paradigm shift of medical consultation focusing on a single specific question to addressing and optimizing the entire patient. This shift toward a broader, more open-ended reason for consultation may present some challenges such as “dumping” where referring surgeons and other specialists signoff their patients after surgery is completed, with internists processing the surgeons’ patients through the hospitalization. These challenges can be mitigated with predefined comanagement agreements with clearly defined roles and collaborative professional relationships.

Nonetheless, given the recent developments in curricula and training competencies mentioned above, internists are better equipped than ever before to put everything together and take care of the medical conditions of the increasingly complex and older surgical patient. For example, if one is consulted to see a patient for postoperative hypertension, it is difficult to not address the patient’s blood sugars in the 300s, lack of venous thromboembolism prophylaxis, delirium, acute renal failure, and acute blood loss anemia. The authors are correct to assert it is critically important to ensure that this input is desired by the referring physician either via verbal communication or comanagement agreements.

The findings of Wang et al. suggest some important future steps in medical consultation to ensure that our trainees and colleagues are prepared to take care of the entire patient regardless of whether the patient is on a consultant or comanagement agreement. This study shows that trainees are exposed to a diverse clinical experience on our medical consultation and comanagement services, which is in accordance with the objectives, assessment tools, and modules of the nationwide curriculum. It is likely that comanagement services will continue to expand as more of our medically complex patients will need either elective or emergency surgeries and surgeons have become less comfortable managing these patients on their own. We also may be asked to participate in quality improvement initiatives in the management of surgical patients, including the “perioperative surgical home programs,” where physicians work on a patient-centered approach to the surgical patient using evidence-based standard clinical care pathways and transitions from before surgery to postdischarge.⁷ We should share our experiences in quality improvement and the patient-centered medical home to ensure that our patients are optimized for surgery and beyond. As Lee Goldman et al. stated in the “Ten Commandments for Effective Consultations,¹” consultative medicine is an important part of an internal medicine practice. Today, more than ever, the consultant or comanagement role or roles need to be carefully defined and clear communication and follow-up are important.

Whenever the principles of effective medical consultation are discussed, a classic article published in 1983 by Lee Goldman et al. is invariably referenced. In the “Ten Commandments for Effective Consultation,” Goldman argued that internists should “determine the question, establish urgency, look for yourself, be as brief as appropriate, be specific, provide contingency plans, honor thy turf, teach with tact, provide direct personal contact, and follow up.”¹ If these Ten Commandments were followed, then the consultation would be more effective and satisfactory for both the consultant and the referring provider. However, with the advent of comanagement in 1994 where internists and surgeons have a “shared responsibility and accountability,”² there has been a shift, and the once-concrete definitions of a specific reason for consult and the nature of “turf” have become blurred. Since 1994, the use of medical consultation and comanagement has skyrocketed, and today, more than 50% of surgical patients have a medical consultation or comanagement.³ This may be due to increased time pressures on surgeons and better outcomes of comanaged patients (eg, fewer postoperative complications, fewer transfers to an intensive care unit for acute medical deterioration, and increased likelihood to discharge to home).⁴

Medical management of surgical patients in the hospital involves a different skill set than that required to manage general medical patients. Accordingly, in 2012, the Accreditation Council for Graduate Medical Education (ACGME) made medical consultation and perioperative care an End of Training Entrustable Professional Activities and ACGME subcompetency. Earlier this year, a nationwide perioperative curriculum for graduate medical education was consisting of eight objective and core topic modules and pretest/posttest questions selected from SHMConsults.com, including assessment and management of perioperative cardiac and pulmonary risk and management of diabetes, perioperative fever, and anticoagulants. Trainees were assessed using the multiple-choice questions, observed mini-cex, and written evaluation of a consultation report. Despite this encouraging development of curricula and competencies for trainees, there are still important gaps in our knowledge of basic patterns for consultation practices. For example, the type of patients and medical conditions currently encountered on our medical consultation and comanagement services had been previously unknown.

In the December issue of the Journal of Hospital Medicine, Wang et al. answer this question through the first cross-sectional multicenter prospective survey to examine medical consultation/comanagement practices since observational studies in the 1970-1990s.⁶ In a sample of 1,264 consultation requests from 11 academic medical centers over four two-week periods from July 2014 through July 2015, they found that the most common requests for consultation were medical management/comanagement, preoperative evaluation, blood pressure management, and other common postoperative complications, including postoperative atrial fibrillation, heart failure, renal failure, hyponatremia, anemia, hypoxia, and altered mental status.⁹ The majority of referrals were from orthopedic surgery and neurosurgery. They also found that medical consultants and comanagers provided comprehensive evaluations where more than a third of encounters addressed issues that were not stated in the initial reason for consult (RFC) and that consultants addressed more than two RFCs per encounter.⁹

These findings illustrate the paradigm shift of medical consultation focusing on a single specific question to addressing and optimizing the entire patient. This shift toward a broader, more open-ended reason for consultation may present some challenges such as “dumping” where referring surgeons and other specialists signoff their patients after surgery is completed, with internists processing the surgeons’ patients through the hospitalization. These challenges can be mitigated with predefined comanagement agreements with clearly defined roles and collaborative professional relationships.

Nonetheless, given the recent developments in curricula and training competencies mentioned above, internists are better equipped than ever before to put everything together and take care of the medical conditions of the increasingly complex and older surgical patient. For example, if one is consulted to see a patient for postoperative hypertension, it is difficult to not address the patient’s blood sugars in the 300s, lack of venous thromboembolism prophylaxis, delirium, acute renal failure, and acute blood loss anemia. The authors are correct to assert it is critically important to ensure that this input is desired by the referring physician either via verbal communication or comanagement agreements.

The findings of Wang et al. suggest some important future steps in medical consultation to ensure that our trainees and colleagues are prepared to take care of the entire patient regardless of whether the patient is on a consultant or comanagement agreement. This study shows that trainees are exposed to a diverse clinical experience on our medical consultation and comanagement services, which is in accordance with the objectives, assessment tools, and modules of the nationwide curriculum. It is likely that comanagement services will continue to expand as more of our medically complex patients will need either elective or emergency surgeries and surgeons have become less comfortable managing these patients on their own. We also may be asked to participate in quality improvement initiatives in the management of surgical patients, including the “perioperative surgical home programs,” where physicians work on a patient-centered approach to the surgical patient using evidence-based standard clinical care pathways and transitions from before surgery to postdischarge.⁷ We should share our experiences in quality improvement and the patient-centered medical home to ensure that our patients are optimized for surgery and beyond. As Lee Goldman et al. stated in the “Ten Commandments for Effective Consultations,¹” consultative medicine is an important part of an internal medicine practice. Today, more than ever, the consultant or comanagement role or roles need to be carefully defined and clear communication and follow-up are important.

The narrative review by Modesto-Lowe et al¹ in this issue on the potential therapeutic use of cannabis for peripheral neuropathy is only the latest in a vogue string of examinations on how medical marijuana may be used to manage complex conditions. While the authors should be lauded for acknowledging that the role of cannabis in treating peripheral neuropathy is far from settled (“the unknown” in their title), the high stakes involved warrant even more stringent scrutiny than they suggest.

See related article

We are in the midst of an epidemic of chronic opioid use with massive repercussions, and it did not start overnight. Mounting calls for liberalizing narcotic use across a broad range of pain conditions accumulated gradually during the patient-advocacy era of the 1990s, with supporting “evidence” coming mostly from small uncontrolled studies, anecdotal reports, and industry pressure.² Although cannabis and opioids are not interchangeable, we should be cautious about concluding that cannabis is effective and that it should be used to treat chronic pain.

CHRONIC PAIN IS COMPLICATED

Peripheral neuropathy, by definition, is a chronic pain condition. Unlike acute pain, chronic pain is characterized by biologic, psychologic, and social complexities that require nuance to manage and study.

Such nuance is lacking in most recent reviews of the medical use of cannabis. The conditions in question are often studied as if they were transient and acute, eg, employing short-term studies and rudimentary measures such as numeric pain-rating scales or other snapshots of pain intensity. Results of these shortsighted assessments are impossible to extrapolate to long-term outcomes.

Whether cannabis therapy for chronic pain conditions is sustainable remains to be seen. Outcomes in chronic pain should not be defined simply by pain reduction, but by other dimensions such as changes in pain-related disability and quality of life, development of pharmacologic tolerance or dependence, adverse effects, and other “collateral damage.” We are far from understanding these issues, which require highly controlled and regulated longitudinal studies.

A recent Cochrane review³ of the efficacy of cannabis-based medicines for chronic neuropathic pain found that harms might outweigh the benefits. The quality of evidence was rated as very low to moderate; the reviewers cited small sample sizes and exclusion of important subgroups of patients (eg, those with substance abuse or other psychiatric comorbidities). Such exclusions are the crux of a major problem with cannabis research: studies are not naturalistic. The gritty reality of chronic pain management is paramount, and failing to consider the high-risk biopsychosocial factors typical of patients with chronic pain is naïve and, frankly, dangerous.

The true danger of cannabis lies in what we already know with certainty. As the authors discuss, cannabis undisputedly results in dose-dependent cognitive and motivational problems. If we are preaching physical therapy and home exercise to counter deconditioning, socialization to reverse depression, cognitive-behavioral therapy to increase coping, returning to work to prevent prolonged disability, and other active measures to prevent pain from becoming chronic, then why would we suggest treatments known to blunt motivation, energy, concentration, and overall mood? As a general central nervous system suppressant,⁴ cannabis works broadly against our best efforts to rehabilitate patients and restore their overall function.

ALL CANNABIS IS NOT THE SAME

The authors use the general term cannabis in their title, yet rightly unpack the differences between medical marijuana, tetrahydrocannabinol (THC), and cannabidiol (CBD). However, in the minds of untrained and pain-stricken patients seeking rapid relief and practical solutions, such distinctions are likely irrelevant.

The danger in the barrage of publications examining cannabis vs medical marijuana vs THC vs CBD is that they all communicate an unintentional yet problematic message: that marijuana of some sort for pain is acceptable to try. And in the face of financial pressures, changing legal landscapes, insurance coverage volatility, and access issues, are patients really going to always secure prescriptions for well-regulated CBD (lacking psychoactive THC) from thoughtful and well-informed physicians, or will they turn to convenient street suppliers?

Simplified perceptions of safety and efficacy across all cannabis products do not help. More troublesome would be to extrapolate safety to other forms of marijuana known to be dangerous, such as synthetic cannabinoids, which in some instances have been associated with catastrophic outcomes.⁵ The slippery slope is real: if the message becomes that some (or most) marijuana is benign or even therapeutic, what is to curb a widespread and unregulated epidemic?

YOUTH AT RISK

Some groups are more vulnerable than others to the potential negative effects of cannabis. In a study at a medical cannabis dispensary in San Francisco,⁶ adolescents and young adults used more marijuana than older users did and had higher rates of “use when bored” and eventual pharmacologic dependence. Sustained use of marijuana by young people places them at risk of serious psychiatric disorders, with numerous studies demonstrating the unfolding of schizophrenia, depression, bipolar disorder, and more.⁷

As the authors point out, cannabis may be contraindicated in those already burdened with mental health problems. If we recall that comorbid psychiatric disorders are the norm rather than the exception in chronic pain conditions,⁸ can we recommend cannabis therapy for most patients with chronic pain with confidence that it will not cause unintended problems? Evidence already shows that even well-established medical marijuana services attract (and perhaps unintentionally debilitate) a certain high-risk demographic: young, socioeconomically disadvantaged men with other comorbid psychiatric and substance use disorders, who ultimately rank poorly in functional health measures compared with the general population.⁹

NOT REEFER MADNESS, BUT REEFER CAUTION

I am not advocating the fear-mongering misinformation campaigns of the past. We should not exaggerate and warn about “reefer madness” or equate marijuana with untruths about random violence or complete bedlam. Nonetheless, concerns for widespread amotivation, worsening psychiatric states, chronic disability, and chemical dependence are very real.

Needed are tightly regulated, well-controlled, and long-term prospective studies involving isolated CBD formulations lacking THC. Over time, perhaps only formulations approved by the US Food and Drug Administration will be embraced. In the meantime, more comprehensive approaches should be recommended, such as team-based interdisciplinary rehabilitation programs that have shown efficacy in handling chronic pain complexities.^10,11

If such steps are unlikely, physicians should nonetheless stand united in sending a message of cautious optimism regarding medical marijuana, educating their patients not only about recently advertised potential yet inconclusive benefits, but also about the well-known and actual certitudes of its harms for use in chronic pain management. There is plenty of bad and worse information to share with patients, and there is a slippery slope of epidemic proportions to be wary about.

The narrative review by Modesto-Lowe et al¹ in this issue on the potential therapeutic use of cannabis for peripheral neuropathy is only the latest in a vogue string of examinations on how medical marijuana may be used to manage complex conditions. While the authors should be lauded for acknowledging that the role of cannabis in treating peripheral neuropathy is far from settled (“the unknown” in their title), the high stakes involved warrant even more stringent scrutiny than they suggest.

See related article

We are in the midst of an epidemic of chronic opioid use with massive repercussions, and it did not start overnight. Mounting calls for liberalizing narcotic use across a broad range of pain conditions accumulated gradually during the patient-advocacy era of the 1990s, with supporting “evidence” coming mostly from small uncontrolled studies, anecdotal reports, and industry pressure.² Although cannabis and opioids are not interchangeable, we should be cautious about concluding that cannabis is effective and that it should be used to treat chronic pain.

CHRONIC PAIN IS COMPLICATED

Peripheral neuropathy, by definition, is a chronic pain condition. Unlike acute pain, chronic pain is characterized by biologic, psychologic, and social complexities that require nuance to manage and study.

Such nuance is lacking in most recent reviews of the medical use of cannabis. The conditions in question are often studied as if they were transient and acute, eg, employing short-term studies and rudimentary measures such as numeric pain-rating scales or other snapshots of pain intensity. Results of these shortsighted assessments are impossible to extrapolate to long-term outcomes.

Whether cannabis therapy for chronic pain conditions is sustainable remains to be seen. Outcomes in chronic pain should not be defined simply by pain reduction, but by other dimensions such as changes in pain-related disability and quality of life, development of pharmacologic tolerance or dependence, adverse effects, and other “collateral damage.” We are far from understanding these issues, which require highly controlled and regulated longitudinal studies.

A recent Cochrane review³ of the efficacy of cannabis-based medicines for chronic neuropathic pain found that harms might outweigh the benefits. The quality of evidence was rated as very low to moderate; the reviewers cited small sample sizes and exclusion of important subgroups of patients (eg, those with substance abuse or other psychiatric comorbidities). Such exclusions are the crux of a major problem with cannabis research: studies are not naturalistic. The gritty reality of chronic pain management is paramount, and failing to consider the high-risk biopsychosocial factors typical of patients with chronic pain is naïve and, frankly, dangerous.

The true danger of cannabis lies in what we already know with certainty. As the authors discuss, cannabis undisputedly results in dose-dependent cognitive and motivational problems. If we are preaching physical therapy and home exercise to counter deconditioning, socialization to reverse depression, cognitive-behavioral therapy to increase coping, returning to work to prevent prolonged disability, and other active measures to prevent pain from becoming chronic, then why would we suggest treatments known to blunt motivation, energy, concentration, and overall mood? As a general central nervous system suppressant,⁴ cannabis works broadly against our best efforts to rehabilitate patients and restore their overall function.

ALL CANNABIS IS NOT THE SAME

The authors use the general term cannabis in their title, yet rightly unpack the differences between medical marijuana, tetrahydrocannabinol (THC), and cannabidiol (CBD). However, in the minds of untrained and pain-stricken patients seeking rapid relief and practical solutions, such distinctions are likely irrelevant.

The danger in the barrage of publications examining cannabis vs medical marijuana vs THC vs CBD is that they all communicate an unintentional yet problematic message: that marijuana of some sort for pain is acceptable to try. And in the face of financial pressures, changing legal landscapes, insurance coverage volatility, and access issues, are patients really going to always secure prescriptions for well-regulated CBD (lacking psychoactive THC) from thoughtful and well-informed physicians, or will they turn to convenient street suppliers?

Simplified perceptions of safety and efficacy across all cannabis products do not help. More troublesome would be to extrapolate safety to other forms of marijuana known to be dangerous, such as synthetic cannabinoids, which in some instances have been associated with catastrophic outcomes.⁵ The slippery slope is real: if the message becomes that some (or most) marijuana is benign or even therapeutic, what is to curb a widespread and unregulated epidemic?

YOUTH AT RISK

Some groups are more vulnerable than others to the potential negative effects of cannabis. In a study at a medical cannabis dispensary in San Francisco,⁶ adolescents and young adults used more marijuana than older users did and had higher rates of “use when bored” and eventual pharmacologic dependence. Sustained use of marijuana by young people places them at risk of serious psychiatric disorders, with numerous studies demonstrating the unfolding of schizophrenia, depression, bipolar disorder, and more.⁷

As the authors point out, cannabis may be contraindicated in those already burdened with mental health problems. If we recall that comorbid psychiatric disorders are the norm rather than the exception in chronic pain conditions,⁸ can we recommend cannabis therapy for most patients with chronic pain with confidence that it will not cause unintended problems? Evidence already shows that even well-established medical marijuana services attract (and perhaps unintentionally debilitate) a certain high-risk demographic: young, socioeconomically disadvantaged men with other comorbid psychiatric and substance use disorders, who ultimately rank poorly in functional health measures compared with the general population.⁹

NOT REEFER MADNESS, BUT REEFER CAUTION

I am not advocating the fear-mongering misinformation campaigns of the past. We should not exaggerate and warn about “reefer madness” or equate marijuana with untruths about random violence or complete bedlam. Nonetheless, concerns for widespread amotivation, worsening psychiatric states, chronic disability, and chemical dependence are very real.

Needed are tightly regulated, well-controlled, and long-term prospective studies involving isolated CBD formulations lacking THC. Over time, perhaps only formulations approved by the US Food and Drug Administration will be embraced. In the meantime, more comprehensive approaches should be recommended, such as team-based interdisciplinary rehabilitation programs that have shown efficacy in handling chronic pain complexities.^10,11

If such steps are unlikely, physicians should nonetheless stand united in sending a message of cautious optimism regarding medical marijuana, educating their patients not only about recently advertised potential yet inconclusive benefits, but also about the well-known and actual certitudes of its harms for use in chronic pain management. There is plenty of bad and worse information to share with patients, and there is a slippery slope of epidemic proportions to be wary about.

The narrative review by Modesto-Lowe et al¹ in this issue on the potential therapeutic use of cannabis for peripheral neuropathy is only the latest in a vogue string of examinations on how medical marijuana may be used to manage complex conditions. While the authors should be lauded for acknowledging that the role of cannabis in treating peripheral neuropathy is far from settled (“the unknown” in their title), the high stakes involved warrant even more stringent scrutiny than they suggest.

See related article

We are in the midst of an epidemic of chronic opioid use with massive repercussions, and it did not start overnight. Mounting calls for liberalizing narcotic use across a broad range of pain conditions accumulated gradually during the patient-advocacy era of the 1990s, with supporting “evidence” coming mostly from small uncontrolled studies, anecdotal reports, and industry pressure.² Although cannabis and opioids are not interchangeable, we should be cautious about concluding that cannabis is effective and that it should be used to treat chronic pain.

CHRONIC PAIN IS COMPLICATED

Peripheral neuropathy, by definition, is a chronic pain condition. Unlike acute pain, chronic pain is characterized by biologic, psychologic, and social complexities that require nuance to manage and study.

Such nuance is lacking in most recent reviews of the medical use of cannabis. The conditions in question are often studied as if they were transient and acute, eg, employing short-term studies and rudimentary measures such as numeric pain-rating scales or other snapshots of pain intensity. Results of these shortsighted assessments are impossible to extrapolate to long-term outcomes.

Whether cannabis therapy for chronic pain conditions is sustainable remains to be seen. Outcomes in chronic pain should not be defined simply by pain reduction, but by other dimensions such as changes in pain-related disability and quality of life, development of pharmacologic tolerance or dependence, adverse effects, and other “collateral damage.” We are far from understanding these issues, which require highly controlled and regulated longitudinal studies.

A recent Cochrane review³ of the efficacy of cannabis-based medicines for chronic neuropathic pain found that harms might outweigh the benefits. The quality of evidence was rated as very low to moderate; the reviewers cited small sample sizes and exclusion of important subgroups of patients (eg, those with substance abuse or other psychiatric comorbidities). Such exclusions are the crux of a major problem with cannabis research: studies are not naturalistic. The gritty reality of chronic pain management is paramount, and failing to consider the high-risk biopsychosocial factors typical of patients with chronic pain is naïve and, frankly, dangerous.

The true danger of cannabis lies in what we already know with certainty. As the authors discuss, cannabis undisputedly results in dose-dependent cognitive and motivational problems. If we are preaching physical therapy and home exercise to counter deconditioning, socialization to reverse depression, cognitive-behavioral therapy to increase coping, returning to work to prevent prolonged disability, and other active measures to prevent pain from becoming chronic, then why would we suggest treatments known to blunt motivation, energy, concentration, and overall mood? As a general central nervous system suppressant,⁴ cannabis works broadly against our best efforts to rehabilitate patients and restore their overall function.

ALL CANNABIS IS NOT THE SAME

The authors use the general term cannabis in their title, yet rightly unpack the differences between medical marijuana, tetrahydrocannabinol (THC), and cannabidiol (CBD). However, in the minds of untrained and pain-stricken patients seeking rapid relief and practical solutions, such distinctions are likely irrelevant.

The danger in the barrage of publications examining cannabis vs medical marijuana vs THC vs CBD is that they all communicate an unintentional yet problematic message: that marijuana of some sort for pain is acceptable to try. And in the face of financial pressures, changing legal landscapes, insurance coverage volatility, and access issues, are patients really going to always secure prescriptions for well-regulated CBD (lacking psychoactive THC) from thoughtful and well-informed physicians, or will they turn to convenient street suppliers?

Simplified perceptions of safety and efficacy across all cannabis products do not help. More troublesome would be to extrapolate safety to other forms of marijuana known to be dangerous, such as synthetic cannabinoids, which in some instances have been associated with catastrophic outcomes.⁵ The slippery slope is real: if the message becomes that some (or most) marijuana is benign or even therapeutic, what is to curb a widespread and unregulated epidemic?

YOUTH AT RISK

Some groups are more vulnerable than others to the potential negative effects of cannabis. In a study at a medical cannabis dispensary in San Francisco,⁶ adolescents and young adults used more marijuana than older users did and had higher rates of “use when bored” and eventual pharmacologic dependence. Sustained use of marijuana by young people places them at risk of serious psychiatric disorders, with numerous studies demonstrating the unfolding of schizophrenia, depression, bipolar disorder, and more.⁷

As the authors point out, cannabis may be contraindicated in those already burdened with mental health problems. If we recall that comorbid psychiatric disorders are the norm rather than the exception in chronic pain conditions,⁸ can we recommend cannabis therapy for most patients with chronic pain with confidence that it will not cause unintended problems? Evidence already shows that even well-established medical marijuana services attract (and perhaps unintentionally debilitate) a certain high-risk demographic: young, socioeconomically disadvantaged men with other comorbid psychiatric and substance use disorders, who ultimately rank poorly in functional health measures compared with the general population.⁹

NOT REEFER MADNESS, BUT REEFER CAUTION

I am not advocating the fear-mongering misinformation campaigns of the past. We should not exaggerate and warn about “reefer madness” or equate marijuana with untruths about random violence or complete bedlam. Nonetheless, concerns for widespread amotivation, worsening psychiatric states, chronic disability, and chemical dependence are very real.

Needed are tightly regulated, well-controlled, and long-term prospective studies involving isolated CBD formulations lacking THC. Over time, perhaps only formulations approved by the US Food and Drug Administration will be embraced. In the meantime, more comprehensive approaches should be recommended, such as team-based interdisciplinary rehabilitation programs that have shown efficacy in handling chronic pain complexities.^10,11

If such steps are unlikely, physicians should nonetheless stand united in sending a message of cautious optimism regarding medical marijuana, educating their patients not only about recently advertised potential yet inconclusive benefits, but also about the well-known and actual certitudes of its harms for use in chronic pain management. There is plenty of bad and worse information to share with patients, and there is a slippery slope of epidemic proportions to be wary about.

After seven years at the helm of the Journal of Hospital Medicine, I am both pleased to hand over the reins and sad to let them go. My time as Editor in Chief has been wonderful, challenging, and fulfilling.

When I began my tenure, JHM managed approximately 350 papers annually, and published 10 times per year. We had no social media presence, a developing editorial sense (and developing Editor in Chief), and a pool of hard-working and passionate Editors. As of this year, we have handled more than 700 papers and are publishing content monthly, online only, and online first. Our dedicated team is deeply passionate about making every paper better through interaction with the authors—whether we accept it for publication or not.

JHM has added a presence on Facebook and Twitter, launched a Twitter Journal Club as a regular offering (#JHMChat), added visual abstracts to our Tweets and Facebook postings, and researched how these novel approaches increase not only the Journal’s social media presence but also its public face. Our efforts in social media were trendsetting in peer-reviewed literature, and the Editors who lead those efforts—Vineet Arora and Charlie Wray—are asked to consult for other journals regularly.

We launched two new series— Choosing Wisely®: Next Steps, and Choosing Wisely®: Things We Do For No Reason—with help from the ABIM Foundation and visionary Editors, Andy Masica, Ann Sheehy, and Lenny Feldman. These papers have pushed Hospitalists and Hospital Medicine to think carefully about the simple things we do every day, to think broadly about how to move past the initial ‘low-hanging fruit’ of value improvement, and point us towards policy and intervention approaches that are disruptive rather than incremental.

A special thank you to Som Mookherjee, Brian Harte, Dan Hunt, and Read Pierce who ably developed the Clinical Care Conundrums and Review series. They are assisted by teams of national correspondents and many contributors who’ve submitted work for those series.

I have been blessed by a team of more than a dozen Associate Editors who have ably, expeditiously, and collegially managed more than 2,000 papers. These Editors work out of a sense of altruism and commitment to Hospital Medicine and have made huge individual contributions to JHM through their reviewing expertise and ensuring that the editorial sense for JHM is as broad and innovative as our field.

Finally, I must thank my core team of Senior Deputy Editors who have shouldered the majority of editorial work, mentored Editors (including me) and Peer Reviewers, and provided strategic guidance.

How peer-reviewed journals are published is changing rapidly. Setting aside the questions of how we consume our medical literature and the transition from paper to digital, old financial models depending on subscriptions and advertising are either dying or evolving into something very different. The challenge is that the new model is very unclear and the old model based on ads and subscriptions is clearly nonviable but is the primary way to support the work of producing a journal. Moving from the current model to one based on clicks, views, or downloads will come down to who will derive benefit from those clicks/downloads, who will be willing to pay to read and learn from the work of authors, or who views that activity as being worthy enough advertise somewhere in that process or to monetize the data garnered from readers’ activities. In addition, many journals, including JHM, are supported by professional societies. While professional societies have a goal to serve their members, the goal of the peer-reviewed journal is to independently and broadly represent the field. One must reflect the other, but space between the two will always be required.

The speed with which research takes place is too slow, and the process of getting evidence into print (much less adopted) is even slower. But, this too is changing; the role of peer review and the publication process is evolving. In order to speed the potential discovery of new innovations, prepublication repositories (such as BioRxViv) are gaining popularity; well-publicized scandals around peer reviewing rings ¹ have not gone unnoticed, and have produced greater interest in using prepublication comments and online discussions as early forms of review. As a result, the disintermediation between scientist and ‘evidence’ is paralleling the disintermediation between events and messengers elsewhere. One need only review Twitter for a moment to get a sense for how crowdsourcing can lead to evidence (or news) generation for good or ill. I agree that while the end of journals (as we understand them now) is upon us, these are also opportunities for JHM as it enters its new phase and a place for leadership. ²

I am proud of what we have done at JHM in the last seven years. We have grown substantially. We have innovated and provided great service to our authors and the field of Hospital Medicine. Our growth and forward-looking approaches to social media and our digital footprint put the journal on a great path towards adapting to the trends in Hospital Medicine research and peer-reviewed publishing. Our focus on being doctors who care for patients and our teams—not just doctors who care for hospitals—is supporting the field and our practice. I look forward to seeing where JHM goes next.

After seven years at the helm of the Journal of Hospital Medicine, I am both pleased to hand over the reins and sad to let them go. My time as Editor in Chief has been wonderful, challenging, and fulfilling.

When I began my tenure, JHM managed approximately 350 papers annually, and published 10 times per year. We had no social media presence, a developing editorial sense (and developing Editor in Chief), and a pool of hard-working and passionate Editors. As of this year, we have handled more than 700 papers and are publishing content monthly, online only, and online first. Our dedicated team is deeply passionate about making every paper better through interaction with the authors—whether we accept it for publication or not.

JHM has added a presence on Facebook and Twitter, launched a Twitter Journal Club as a regular offering (#JHMChat), added visual abstracts to our Tweets and Facebook postings, and researched how these novel approaches increase not only the Journal’s social media presence but also its public face. Our efforts in social media were trendsetting in peer-reviewed literature, and the Editors who lead those efforts—Vineet Arora and Charlie Wray—are asked to consult for other journals regularly.

We launched two new series— Choosing Wisely®: Next Steps, and Choosing Wisely®: Things We Do For No Reason—with help from the ABIM Foundation and visionary Editors, Andy Masica, Ann Sheehy, and Lenny Feldman. These papers have pushed Hospitalists and Hospital Medicine to think carefully about the simple things we do every day, to think broadly about how to move past the initial ‘low-hanging fruit’ of value improvement, and point us towards policy and intervention approaches that are disruptive rather than incremental.

A special thank you to Som Mookherjee, Brian Harte, Dan Hunt, and Read Pierce who ably developed the Clinical Care Conundrums and Review series. They are assisted by teams of national correspondents and many contributors who’ve submitted work for those series.

I have been blessed by a team of more than a dozen Associate Editors who have ably, expeditiously, and collegially managed more than 2,000 papers. These Editors work out of a sense of altruism and commitment to Hospital Medicine and have made huge individual contributions to JHM through their reviewing expertise and ensuring that the editorial sense for JHM is as broad and innovative as our field.

Finally, I must thank my core team of Senior Deputy Editors who have shouldered the majority of editorial work, mentored Editors (including me) and Peer Reviewers, and provided strategic guidance.

How peer-reviewed journals are published is changing rapidly. Setting aside the questions of how we consume our medical literature and the transition from paper to digital, old financial models depending on subscriptions and advertising are either dying or evolving into something very different. The challenge is that the new model is very unclear and the old model based on ads and subscriptions is clearly nonviable but is the primary way to support the work of producing a journal. Moving from the current model to one based on clicks, views, or downloads will come down to who will derive benefit from those clicks/downloads, who will be willing to pay to read and learn from the work of authors, or who views that activity as being worthy enough advertise somewhere in that process or to monetize the data garnered from readers’ activities. In addition, many journals, including JHM, are supported by professional societies. While professional societies have a goal to serve their members, the goal of the peer-reviewed journal is to independently and broadly represent the field. One must reflect the other, but space between the two will always be required.

The speed with which research takes place is too slow, and the process of getting evidence into print (much less adopted) is even slower. But, this too is changing; the role of peer review and the publication process is evolving. In order to speed the potential discovery of new innovations, prepublication repositories (such as BioRxViv) are gaining popularity; well-publicized scandals around peer reviewing rings ¹ have not gone unnoticed, and have produced greater interest in using prepublication comments and online discussions as early forms of review. As a result, the disintermediation between scientist and ‘evidence’ is paralleling the disintermediation between events and messengers elsewhere. One need only review Twitter for a moment to get a sense for how crowdsourcing can lead to evidence (or news) generation for good or ill. I agree that while the end of journals (as we understand them now) is upon us, these are also opportunities for JHM as it enters its new phase and a place for leadership. ²

I am proud of what we have done at JHM in the last seven years. We have grown substantially. We have innovated and provided great service to our authors and the field of Hospital Medicine. Our growth and forward-looking approaches to social media and our digital footprint put the journal on a great path towards adapting to the trends in Hospital Medicine research and peer-reviewed publishing. Our focus on being doctors who care for patients and our teams—not just doctors who care for hospitals—is supporting the field and our practice. I look forward to seeing where JHM goes next.

After seven years at the helm of the Journal of Hospital Medicine, I am both pleased to hand over the reins and sad to let them go. My time as Editor in Chief has been wonderful, challenging, and fulfilling.

When I began my tenure, JHM managed approximately 350 papers annually, and published 10 times per year. We had no social media presence, a developing editorial sense (and developing Editor in Chief), and a pool of hard-working and passionate Editors. As of this year, we have handled more than 700 papers and are publishing content monthly, online only, and online first. Our dedicated team is deeply passionate about making every paper better through interaction with the authors—whether we accept it for publication or not.

JHM has added a presence on Facebook and Twitter, launched a Twitter Journal Club as a regular offering (#JHMChat), added visual abstracts to our Tweets and Facebook postings, and researched how these novel approaches increase not only the Journal’s social media presence but also its public face. Our efforts in social media were trendsetting in peer-reviewed literature, and the Editors who lead those efforts—Vineet Arora and Charlie Wray—are asked to consult for other journals regularly.

We launched two new series— Choosing Wisely®: Next Steps, and Choosing Wisely®: Things We Do For No Reason—with help from the ABIM Foundation and visionary Editors, Andy Masica, Ann Sheehy, and Lenny Feldman. These papers have pushed Hospitalists and Hospital Medicine to think carefully about the simple things we do every day, to think broadly about how to move past the initial ‘low-hanging fruit’ of value improvement, and point us towards policy and intervention approaches that are disruptive rather than incremental.

A special thank you to Som Mookherjee, Brian Harte, Dan Hunt, and Read Pierce who ably developed the Clinical Care Conundrums and Review series. They are assisted by teams of national correspondents and many contributors who’ve submitted work for those series.

I have been blessed by a team of more than a dozen Associate Editors who have ably, expeditiously, and collegially managed more than 2,000 papers. These Editors work out of a sense of altruism and commitment to Hospital Medicine and have made huge individual contributions to JHM through their reviewing expertise and ensuring that the editorial sense for JHM is as broad and innovative as our field.

Finally, I must thank my core team of Senior Deputy Editors who have shouldered the majority of editorial work, mentored Editors (including me) and Peer Reviewers, and provided strategic guidance.

How peer-reviewed journals are published is changing rapidly. Setting aside the questions of how we consume our medical literature and the transition from paper to digital, old financial models depending on subscriptions and advertising are either dying or evolving into something very different. The challenge is that the new model is very unclear and the old model based on ads and subscriptions is clearly nonviable but is the primary way to support the work of producing a journal. Moving from the current model to one based on clicks, views, or downloads will come down to who will derive benefit from those clicks/downloads, who will be willing to pay to read and learn from the work of authors, or who views that activity as being worthy enough advertise somewhere in that process or to monetize the data garnered from readers’ activities. In addition, many journals, including JHM, are supported by professional societies. While professional societies have a goal to serve their members, the goal of the peer-reviewed journal is to independently and broadly represent the field. One must reflect the other, but space between the two will always be required.

The speed with which research takes place is too slow, and the process of getting evidence into print (much less adopted) is even slower. But, this too is changing; the role of peer review and the publication process is evolving. In order to speed the potential discovery of new innovations, prepublication repositories (such as BioRxViv) are gaining popularity; well-publicized scandals around peer reviewing rings ¹ have not gone unnoticed, and have produced greater interest in using prepublication comments and online discussions as early forms of review. As a result, the disintermediation between scientist and ‘evidence’ is paralleling the disintermediation between events and messengers elsewhere. One need only review Twitter for a moment to get a sense for how crowdsourcing can lead to evidence (or news) generation for good or ill. I agree that while the end of journals (as we understand them now) is upon us, these are also opportunities for JHM as it enters its new phase and a place for leadership. ²

I am proud of what we have done at JHM in the last seven years. We have grown substantially. We have innovated and provided great service to our authors and the field of Hospital Medicine. Our growth and forward-looking approaches to social media and our digital footprint put the journal on a great path towards adapting to the trends in Hospital Medicine research and peer-reviewed publishing. Our focus on being doctors who care for patients and our teams—not just doctors who care for hospitals—is supporting the field and our practice. I look forward to seeing where JHM goes next.

One of the least taught yet most complicated tasks confronting new trainees is the bewildering process of discharging a patient. On an internal medicine service, this process can often resemble a Rube Goldberg machine, in which a “simple” task is accomplished through a series of interconnected, almost comically convoluted, yet separate steps that are triggered one after another and must be executed perfectly in sequence for success. It seems easy at first; just tap out a few sentences in the discharge paperwork, do a quick medication reconciliation, and a click of a button later, voila! The patient magically falls off the list and is on their merry way home. In reality, it only takes one wrench thrown into the Rube Goldberg machine to take down the whole operation. Much to the chagrin of internal medicine interns across the country, residents quickly learn that discharge planning is usually far from straightforward and that a myriad of obstacles (often dynamic and frustratingly unpredictable) can stand in the way of a successful discharge.

While some surgical services can streamline discharge processes to target defined lengths of stay based on a particular diagnosis, general medicine patients tend to have greater numbers of comorbid conditions, complex hospital courses, and wider variation in access to posthospital healthcare. In addition, there is very little formal instruction in transitions of care, and most residents identify direct patient care (learning by doing) as the primary mode of education.^1,2 Struggling through the process of finding an appropriate placement, ensuring adequate outpatient follow-up, and untangling a jumbled mess of a medication reconciliation is often the only way that housestaff learn the Sisyphean task of transitioning care out of the hospital. The unpredictability and intensity of patient care adds to the ever growing list of competing demands on the time and attention of residents. Attendings face pressure on all sides to not only provide exemplary patient care and an educational experience but also to optimize hospital throughput by discharging patients as soon as possible (and ideally before noon). No wonder that the discharge process can threaten to unravel at any time, with delays and complications in discharge metamorphosing into increased length of stay (LOS), poorer outcomes, and increased 30-day readmission rates. As on-the-ground providers, what realities do we face when challenging ourselves to discharge patients before noon, and what practical changes in our workflow can we make to reach this goal?

In this month’s Journal of Hospital Medicine, Zoucha et al. examine these questions in real time by identifying barriers preventing both “definite” and “possible” discharges at three representative time points over the course of randomly chosen weekdays. They surveyed both housestaff and attendings at five academic hospitals across the United States, and the majority of patients were cared for on teaching services.³ Reflecting the inherent differences in workflow between teaching and nonteaching services, delays in definite discharges on teaching services were most often hindered by completing rounds and the need to staff the patient with the attending, whereas nonresident services identified other patient-care-related (both urgent and nonurgent) issues to be the culprits. Late-afternoon discharges were delayed on teaching services due to outstanding paperwork and follow-up arrangements, both of which most senior residents are keenly aware of and make their best effort to complete ahead of time. Patients designated as “possible” discharges were awaiting clinical improvement and resolution of disposition issues dependent on social work and safe placement, which reasonably seemed independent of service type. These descriptive findings suggest that nonresident services are more efficient than resident teams, and we are keen to identify novel solutions, such as dedicated discharge coordinators,⁴ to facilitate the discharge process on resident teams without detracting from the educational value of the rotation.

Zoucha et al. also found that factors beyond our control (having a lower daily census, attending on a nonresident service) were significantly associated with both earlier discharge order entry times and the actual time of patient discharge.³ While it is tempting to foist the entirety of the blame on extrinsic factors such as discharge placement and insurance issues, the reality is there might be some workflow changes that could expedite the discharge process. The authors are correct to emphasize that rounding style, in which discharges are prioritized to be seen first, is a behavior modification worth targeting. The percentage of teams that routinely see discharges first is not well studied, as other factors, such as clinically unstable patients, new admissions from overnight, and even mundane characteristics such as geographic location in the hospital, can also compete for prioritization in rounding order. Given the authors’ findings, we are eager to see further work in this area as prioritization of discharges during rounds could conceivably be studied within the context of a randomized controlled trial. Other innovations in rounding styles such as rounding-in-flow⁵ (in which all tasks are completed for a single patient before rounding on the next patient) can also significantly reduce the time to discharge order placement.

With help from the Penn Medicine Center for Health Care Innovation, we are actively studying bottlenecks in the discharge process by developing an interactive platform focused on delivering real-time information to all members of the healthcare team. Rapid rounds are held every morning with the attending physician, floor nursing leadership, physical therapy, social worker, and case management to quickly identify pending tasks, anticipated disposition, and a target date of discharge. Efficiency is key, as each team is limited to approximately 5-10 minutes. Previous studies (mostly pre–post studies) have shown that this simple intervention significantly reduced LOS,^6,7 increased rates of discharge before noon,⁸ and was improved by electronic tracking tools.⁹ Our multidisciplinary rounds are unique in that information is then entered into an intuitive, web-based platform, which allows consolidation and analysis that permits generation of real-time statistics. By standardizing the discharge planning process, we hope to streamline a previously fragmented process and maximize the efficiency of hospital resource utilization.

Ultimately, high-quality care of complex patients on internal medicine services from admission to discharge requires hard work, smart utilization of resources, and a little bit of luck. There may not be a secret ingredient that guarantees perfectly efficient discharges 100% of the time, but this study inspires us to ponder additional approaches to this longstanding problem. The authors are to be congratulated for a rigorous study that illuminates where we as healthcare providers are able to realistically intervene to expedite the discharge process. First, having a lower census cap may not be possible in this era of maximal hospital usage, but this work suggests that thoughtful management of time on rounds may be a way to address the underlying problem. Secondly, the superior efficiency of nonteaching services may merely reflect the increased experience of the providers, and a realistic solution could be to implement a formal curriculum to educate housestaff about the discharge process, which would simultaneously address residency competency standards for transitions of care. Finally, the role of innovative informatics tools will surely open further avenues of investigation, as we continually evolve in response to intensifying standards of modern, efficient healthcare delivery in the 21^st century. It may not be possible to eliminate the complexity from this particular Rube Goldberg machine, but taking the steps above may allow us to implement as many fail-safes as we can.

Disclosures

The authors have nothing to disclose.

One of the least taught yet most complicated tasks confronting new trainees is the bewildering process of discharging a patient. On an internal medicine service, this process can often resemble a Rube Goldberg machine, in which a “simple” task is accomplished through a series of interconnected, almost comically convoluted, yet separate steps that are triggered one after another and must be executed perfectly in sequence for success. It seems easy at first; just tap out a few sentences in the discharge paperwork, do a quick medication reconciliation, and a click of a button later, voila! The patient magically falls off the list and is on their merry way home. In reality, it only takes one wrench thrown into the Rube Goldberg machine to take down the whole operation. Much to the chagrin of internal medicine interns across the country, residents quickly learn that discharge planning is usually far from straightforward and that a myriad of obstacles (often dynamic and frustratingly unpredictable) can stand in the way of a successful discharge.

While some surgical services can streamline discharge processes to target defined lengths of stay based on a particular diagnosis, general medicine patients tend to have greater numbers of comorbid conditions, complex hospital courses, and wider variation in access to posthospital healthcare. In addition, there is very little formal instruction in transitions of care, and most residents identify direct patient care (learning by doing) as the primary mode of education.^1,2 Struggling through the process of finding an appropriate placement, ensuring adequate outpatient follow-up, and untangling a jumbled mess of a medication reconciliation is often the only way that housestaff learn the Sisyphean task of transitioning care out of the hospital. The unpredictability and intensity of patient care adds to the ever growing list of competing demands on the time and attention of residents. Attendings face pressure on all sides to not only provide exemplary patient care and an educational experience but also to optimize hospital throughput by discharging patients as soon as possible (and ideally before noon). No wonder that the discharge process can threaten to unravel at any time, with delays and complications in discharge metamorphosing into increased length of stay (LOS), poorer outcomes, and increased 30-day readmission rates. As on-the-ground providers, what realities do we face when challenging ourselves to discharge patients before noon, and what practical changes in our workflow can we make to reach this goal?

In this month’s Journal of Hospital Medicine, Zoucha et al. examine these questions in real time by identifying barriers preventing both “definite” and “possible” discharges at three representative time points over the course of randomly chosen weekdays. They surveyed both housestaff and attendings at five academic hospitals across the United States, and the majority of patients were cared for on teaching services.³ Reflecting the inherent differences in workflow between teaching and nonteaching services, delays in definite discharges on teaching services were most often hindered by completing rounds and the need to staff the patient with the attending, whereas nonresident services identified other patient-care-related (both urgent and nonurgent) issues to be the culprits. Late-afternoon discharges were delayed on teaching services due to outstanding paperwork and follow-up arrangements, both of which most senior residents are keenly aware of and make their best effort to complete ahead of time. Patients designated as “possible” discharges were awaiting clinical improvement and resolution of disposition issues dependent on social work and safe placement, which reasonably seemed independent of service type. These descriptive findings suggest that nonresident services are more efficient than resident teams, and we are keen to identify novel solutions, such as dedicated discharge coordinators,⁴ to facilitate the discharge process on resident teams without detracting from the educational value of the rotation.

Zoucha et al. also found that factors beyond our control (having a lower daily census, attending on a nonresident service) were significantly associated with both earlier discharge order entry times and the actual time of patient discharge.³ While it is tempting to foist the entirety of the blame on extrinsic factors such as discharge placement and insurance issues, the reality is there might be some workflow changes that could expedite the discharge process. The authors are correct to emphasize that rounding style, in which discharges are prioritized to be seen first, is a behavior modification worth targeting. The percentage of teams that routinely see discharges first is not well studied, as other factors, such as clinically unstable patients, new admissions from overnight, and even mundane characteristics such as geographic location in the hospital, can also compete for prioritization in rounding order. Given the authors’ findings, we are eager to see further work in this area as prioritization of discharges during rounds could conceivably be studied within the context of a randomized controlled trial. Other innovations in rounding styles such as rounding-in-flow⁵ (in which all tasks are completed for a single patient before rounding on the next patient) can also significantly reduce the time to discharge order placement.

With help from the Penn Medicine Center for Health Care Innovation, we are actively studying bottlenecks in the discharge process by developing an interactive platform focused on delivering real-time information to all members of the healthcare team. Rapid rounds are held every morning with the attending physician, floor nursing leadership, physical therapy, social worker, and case management to quickly identify pending tasks, anticipated disposition, and a target date of discharge. Efficiency is key, as each team is limited to approximately 5-10 minutes. Previous studies (mostly pre–post studies) have shown that this simple intervention significantly reduced LOS,^6,7 increased rates of discharge before noon,⁸ and was improved by electronic tracking tools.⁹ Our multidisciplinary rounds are unique in that information is then entered into an intuitive, web-based platform, which allows consolidation and analysis that permits generation of real-time statistics. By standardizing the discharge planning process, we hope to streamline a previously fragmented process and maximize the efficiency of hospital resource utilization.

Ultimately, high-quality care of complex patients on internal medicine services from admission to discharge requires hard work, smart utilization of resources, and a little bit of luck. There may not be a secret ingredient that guarantees perfectly efficient discharges 100% of the time, but this study inspires us to ponder additional approaches to this longstanding problem. The authors are to be congratulated for a rigorous study that illuminates where we as healthcare providers are able to realistically intervene to expedite the discharge process. First, having a lower census cap may not be possible in this era of maximal hospital usage, but this work suggests that thoughtful management of time on rounds may be a way to address the underlying problem. Secondly, the superior efficiency of nonteaching services may merely reflect the increased experience of the providers, and a realistic solution could be to implement a formal curriculum to educate housestaff about the discharge process, which would simultaneously address residency competency standards for transitions of care. Finally, the role of innovative informatics tools will surely open further avenues of investigation, as we continually evolve in response to intensifying standards of modern, efficient healthcare delivery in the 21^st century. It may not be possible to eliminate the complexity from this particular Rube Goldberg machine, but taking the steps above may allow us to implement as many fail-safes as we can.

Disclosures

The authors have nothing to disclose.

One of the least taught yet most complicated tasks confronting new trainees is the bewildering process of discharging a patient. On an internal medicine service, this process can often resemble a Rube Goldberg machine, in which a “simple” task is accomplished through a series of interconnected, almost comically convoluted, yet separate steps that are triggered one after another and must be executed perfectly in sequence for success. It seems easy at first; just tap out a few sentences in the discharge paperwork, do a quick medication reconciliation, and a click of a button later, voila! The patient magically falls off the list and is on their merry way home. In reality, it only takes one wrench thrown into the Rube Goldberg machine to take down the whole operation. Much to the chagrin of internal medicine interns across the country, residents quickly learn that discharge planning is usually far from straightforward and that a myriad of obstacles (often dynamic and frustratingly unpredictable) can stand in the way of a successful discharge.

While some surgical services can streamline discharge processes to target defined lengths of stay based on a particular diagnosis, general medicine patients tend to have greater numbers of comorbid conditions, complex hospital courses, and wider variation in access to posthospital healthcare. In addition, there is very little formal instruction in transitions of care, and most residents identify direct patient care (learning by doing) as the primary mode of education.^1,2 Struggling through the process of finding an appropriate placement, ensuring adequate outpatient follow-up, and untangling a jumbled mess of a medication reconciliation is often the only way that housestaff learn the Sisyphean task of transitioning care out of the hospital. The unpredictability and intensity of patient care adds to the ever growing list of competing demands on the time and attention of residents. Attendings face pressure on all sides to not only provide exemplary patient care and an educational experience but also to optimize hospital throughput by discharging patients as soon as possible (and ideally before noon). No wonder that the discharge process can threaten to unravel at any time, with delays and complications in discharge metamorphosing into increased length of stay (LOS), poorer outcomes, and increased 30-day readmission rates. As on-the-ground providers, what realities do we face when challenging ourselves to discharge patients before noon, and what practical changes in our workflow can we make to reach this goal?

In this month’s Journal of Hospital Medicine, Zoucha et al. examine these questions in real time by identifying barriers preventing both “definite” and “possible” discharges at three representative time points over the course of randomly chosen weekdays. They surveyed both housestaff and attendings at five academic hospitals across the United States, and the majority of patients were cared for on teaching services.³ Reflecting the inherent differences in workflow between teaching and nonteaching services, delays in definite discharges on teaching services were most often hindered by completing rounds and the need to staff the patient with the attending, whereas nonresident services identified other patient-care-related (both urgent and nonurgent) issues to be the culprits. Late-afternoon discharges were delayed on teaching services due to outstanding paperwork and follow-up arrangements, both of which most senior residents are keenly aware of and make their best effort to complete ahead of time. Patients designated as “possible” discharges were awaiting clinical improvement and resolution of disposition issues dependent on social work and safe placement, which reasonably seemed independent of service type. These descriptive findings suggest that nonresident services are more efficient than resident teams, and we are keen to identify novel solutions, such as dedicated discharge coordinators,⁴ to facilitate the discharge process on resident teams without detracting from the educational value of the rotation.

Zoucha et al. also found that factors beyond our control (having a lower daily census, attending on a nonresident service) were significantly associated with both earlier discharge order entry times and the actual time of patient discharge.³ While it is tempting to foist the entirety of the blame on extrinsic factors such as discharge placement and insurance issues, the reality is there might be some workflow changes that could expedite the discharge process. The authors are correct to emphasize that rounding style, in which discharges are prioritized to be seen first, is a behavior modification worth targeting. The percentage of teams that routinely see discharges first is not well studied, as other factors, such as clinically unstable patients, new admissions from overnight, and even mundane characteristics such as geographic location in the hospital, can also compete for prioritization in rounding order. Given the authors’ findings, we are eager to see further work in this area as prioritization of discharges during rounds could conceivably be studied within the context of a randomized controlled trial. Other innovations in rounding styles such as rounding-in-flow⁵ (in which all tasks are completed for a single patient before rounding on the next patient) can also significantly reduce the time to discharge order placement.

With help from the Penn Medicine Center for Health Care Innovation, we are actively studying bottlenecks in the discharge process by developing an interactive platform focused on delivering real-time information to all members of the healthcare team. Rapid rounds are held every morning with the attending physician, floor nursing leadership, physical therapy, social worker, and case management to quickly identify pending tasks, anticipated disposition, and a target date of discharge. Efficiency is key, as each team is limited to approximately 5-10 minutes. Previous studies (mostly pre–post studies) have shown that this simple intervention significantly reduced LOS,^6,7 increased rates of discharge before noon,⁸ and was improved by electronic tracking tools.⁹ Our multidisciplinary rounds are unique in that information is then entered into an intuitive, web-based platform, which allows consolidation and analysis that permits generation of real-time statistics. By standardizing the discharge planning process, we hope to streamline a previously fragmented process and maximize the efficiency of hospital resource utilization.

Ultimately, high-quality care of complex patients on internal medicine services from admission to discharge requires hard work, smart utilization of resources, and a little bit of luck. There may not be a secret ingredient that guarantees perfectly efficient discharges 100% of the time, but this study inspires us to ponder additional approaches to this longstanding problem. The authors are to be congratulated for a rigorous study that illuminates where we as healthcare providers are able to realistically intervene to expedite the discharge process. First, having a lower census cap may not be possible in this era of maximal hospital usage, but this work suggests that thoughtful management of time on rounds may be a way to address the underlying problem. Secondly, the superior efficiency of nonteaching services may merely reflect the increased experience of the providers, and a realistic solution could be to implement a formal curriculum to educate housestaff about the discharge process, which would simultaneously address residency competency standards for transitions of care. Finally, the role of innovative informatics tools will surely open further avenues of investigation, as we continually evolve in response to intensifying standards of modern, efficient healthcare delivery in the 21^st century. It may not be possible to eliminate the complexity from this particular Rube Goldberg machine, but taking the steps above may allow us to implement as many fail-safes as we can.

Disclosures

The authors have nothing to disclose.

In this issue of the Journal of Hospital Medicine, the paper by Gottenborg et al. captures the experiences of female academic hospitalists navigating one of the most significant transitions they will face—becoming new mothers.¹ This article gives an accessible voice to impersonal statistics about the barriers women physicians encounter within and across specialties in academia. The challenges and anecdotes shared by the study participants were eminently relatable and captured the all-too-familiar circumstances most of us with children have faced in our careers as physician mothers.

This study uses qualitative research methods to illustrate the hurdles faced by mothers in hospital medicine beyond what is demonstrated by quantitative measures and provides the helpful step of proposing some solutions to the obstacles they have faced. While the sample size was very small, the women interviewed were diverse in their years in practice, geographic distribution, and percent clinical effort, providing evidence that the themes discussed prevail across demographic categories.

The snowball sampling via the Society of Hospital Medicine committees may not have yielded a representative sample of female hospitalists. It seems possible that women who are involved in this type of leadership may be better supported and/or have different work schedules than their peers who are not in leadership positions. We also wish there had been more emphasis on the systemic and structural factors that can improve the quality of life of physician mothers. These policies include paternity leave and other creative ways of acknowledging the useful skills and experience that motherhood brings to bear on clinical practice, such as increased empathy and compassion, as mentioned by one of the study participants.

Even with the aforementioned limitations, this study is important because it combines authentic quotes from practicing academic hospitalists with concrete and tangible suggestions for structural changes. The most striking element is that the majority of the study participants experienced uncertainty and a lack of transparency around parental leave policies. As nearly half of hospitalists are women and 80% are under age 40,² it seems unimaginable that there would not be explicit policies in place for what is a common and largely anticipated life event. Medicine has made great strides toward gender equality, but we are unlikely to ever reach the goal of true parity without openly addressing the disproportionate effect of childbearing and child rearing on women physicians. Standardized, readily available, and equitable parental leave policies (for both birth parents and nonbirth parents) are the first and most critical step.

The absence of standard leave policies naturally puts physician mothers in the position of having to negotiate or “haggle” with various supervisors, the majority of whom are male division chiefs and department chairs,³ which places all parties in an uncomfortable position, further reinforcing inequities and sowing discord and resentment. Having formal policies around leave protects not only those who utilize parental leave but also the other members of a hospital medicine practice who take on the workload of the person on leave.

Uncertainty around how to address the increased clinical load and for how long, also creates anxiety among other group members and may lead to feelings of bitterness toward clinicians on leave, further contributing to the negative impact of new parenthood on female hospitalists. We can think of no other medical circumstance in which there is as much advance notice of the need for significant time away from work. Yet pregnancy, which is subject to complications and emergencies just like other medical conditions, is treated with so little concern that one may be asked to arrange for their own coverage during such an emergency, as one study subject reported.

We also empathize with the study participants’ reports of feeling that supervisors often mentally discounted their ability to participate in projects on return to work. These pernicious assumptions can compound a cycle of lost productivity, disengagement, and attrition from the workforce.

Female hospitalists returning from leave face additional challenges that place an undue burden on their professional activities, most notably related to breastfeeding. This is particularly relevant in the context of the intensity inherent in practicing hospital medicine, which includes long days of being the primary provider for acutely ill inpatients, as well as long stretches of many consecutive days when it may not be possible to return home before children’s bedtime. Even at our own institution, which has been recognized as a “Healthy Mothers Workplace,” breastfeeding accommodations are not set up to allow for ongoing clinical activities while taking time to express breastmilk, and the clinical schedule does not build in adjustments for this time-consuming and psychologically taxing commitment. Breastfeeding for at least one year is the medical recommendation of the American Academy of Pediatrics in line with a substantial body of evidence.⁴ One quote from the article poignantly notes, “Pumping every 3-4 hours: stopping what you’re doing, finding an empty room to pump, finding a place to store your milk, then going back to work, three times per shift, for the next 9 months of your life, was hell.” If we cannot enable our own medical providers to follow evidence-based recommendations, how can we possibly expect this of our patients?

The notion of women “having it all” is an impossible ideal—both work and life outside of work will inevitably require tradeoffs. However, there is an abundance of evidence and recommendations for concrete steps that can be taken to improve the experience of female physicians who have children. These include formal policies for childbearing and child rearing leave (the American Academy of Pediatrics recommends at least six to nine months⁵), convenient space and protected time for pumping milk during the first year, on-site childcare services and back-up child care, and flexible work schedules.⁶ It is time to stop treating childbirth among female physicians like an unexpected inconvenience and acknowledge the undeniable demographics of physicians in hospital medicine and the duty of healthcare systems and hospital medicine leaders to effectively plan for the needs of half of their workforce.

Disclosures

Neither of the authors have any financial conflicts of interest to disclose.

In this issue of the Journal of Hospital Medicine, the paper by Gottenborg et al. captures the experiences of female academic hospitalists navigating one of the most significant transitions they will face—becoming new mothers.¹ This article gives an accessible voice to impersonal statistics about the barriers women physicians encounter within and across specialties in academia. The challenges and anecdotes shared by the study participants were eminently relatable and captured the all-too-familiar circumstances most of us with children have faced in our careers as physician mothers.

This study uses qualitative research methods to illustrate the hurdles faced by mothers in hospital medicine beyond what is demonstrated by quantitative measures and provides the helpful step of proposing some solutions to the obstacles they have faced. While the sample size was very small, the women interviewed were diverse in their years in practice, geographic distribution, and percent clinical effort, providing evidence that the themes discussed prevail across demographic categories.

The snowball sampling via the Society of Hospital Medicine committees may not have yielded a representative sample of female hospitalists. It seems possible that women who are involved in this type of leadership may be better supported and/or have different work schedules than their peers who are not in leadership positions. We also wish there had been more emphasis on the systemic and structural factors that can improve the quality of life of physician mothers. These policies include paternity leave and other creative ways of acknowledging the useful skills and experience that motherhood brings to bear on clinical practice, such as increased empathy and compassion, as mentioned by one of the study participants.

Even with the aforementioned limitations, this study is important because it combines authentic quotes from practicing academic hospitalists with concrete and tangible suggestions for structural changes. The most striking element is that the majority of the study participants experienced uncertainty and a lack of transparency around parental leave policies. As nearly half of hospitalists are women and 80% are under age 40,² it seems unimaginable that there would not be explicit policies in place for what is a common and largely anticipated life event. Medicine has made great strides toward gender equality, but we are unlikely to ever reach the goal of true parity without openly addressing the disproportionate effect of childbearing and child rearing on women physicians. Standardized, readily available, and equitable parental leave policies (for both birth parents and nonbirth parents) are the first and most critical step.

The absence of standard leave policies naturally puts physician mothers in the position of having to negotiate or “haggle” with various supervisors, the majority of whom are male division chiefs and department chairs,³ which places all parties in an uncomfortable position, further reinforcing inequities and sowing discord and resentment. Having formal policies around leave protects not only those who utilize parental leave but also the other members of a hospital medicine practice who take on the workload of the person on leave.

Uncertainty around how to address the increased clinical load and for how long, also creates anxiety among other group members and may lead to feelings of bitterness toward clinicians on leave, further contributing to the negative impact of new parenthood on female hospitalists. We can think of no other medical circumstance in which there is as much advance notice of the need for significant time away from work. Yet pregnancy, which is subject to complications and emergencies just like other medical conditions, is treated with so little concern that one may be asked to arrange for their own coverage during such an emergency, as one study subject reported.

We also empathize with the study participants’ reports of feeling that supervisors often mentally discounted their ability to participate in projects on return to work. These pernicious assumptions can compound a cycle of lost productivity, disengagement, and attrition from the workforce.

Female hospitalists returning from leave face additional challenges that place an undue burden on their professional activities, most notably related to breastfeeding. This is particularly relevant in the context of the intensity inherent in practicing hospital medicine, which includes long days of being the primary provider for acutely ill inpatients, as well as long stretches of many consecutive days when it may not be possible to return home before children’s bedtime. Even at our own institution, which has been recognized as a “Healthy Mothers Workplace,” breastfeeding accommodations are not set up to allow for ongoing clinical activities while taking time to express breastmilk, and the clinical schedule does not build in adjustments for this time-consuming and psychologically taxing commitment. Breastfeeding for at least one year is the medical recommendation of the American Academy of Pediatrics in line with a substantial body of evidence.⁴ One quote from the article poignantly notes, “Pumping every 3-4 hours: stopping what you’re doing, finding an empty room to pump, finding a place to store your milk, then going back to work, three times per shift, for the next 9 months of your life, was hell.” If we cannot enable our own medical providers to follow evidence-based recommendations, how can we possibly expect this of our patients?

The notion of women “having it all” is an impossible ideal—both work and life outside of work will inevitably require tradeoffs. However, there is an abundance of evidence and recommendations for concrete steps that can be taken to improve the experience of female physicians who have children. These include formal policies for childbearing and child rearing leave (the American Academy of Pediatrics recommends at least six to nine months⁵), convenient space and protected time for pumping milk during the first year, on-site childcare services and back-up child care, and flexible work schedules.⁶ It is time to stop treating childbirth among female physicians like an unexpected inconvenience and acknowledge the undeniable demographics of physicians in hospital medicine and the duty of healthcare systems and hospital medicine leaders to effectively plan for the needs of half of their workforce.

Disclosures

Neither of the authors have any financial conflicts of interest to disclose.

In this issue of the Journal of Hospital Medicine, the paper by Gottenborg et al. captures the experiences of female academic hospitalists navigating one of the most significant transitions they will face—becoming new mothers.¹ This article gives an accessible voice to impersonal statistics about the barriers women physicians encounter within and across specialties in academia. The challenges and anecdotes shared by the study participants were eminently relatable and captured the all-too-familiar circumstances most of us with children have faced in our careers as physician mothers.

This study uses qualitative research methods to illustrate the hurdles faced by mothers in hospital medicine beyond what is demonstrated by quantitative measures and provides the helpful step of proposing some solutions to the obstacles they have faced. While the sample size was very small, the women interviewed were diverse in their years in practice, geographic distribution, and percent clinical effort, providing evidence that the themes discussed prevail across demographic categories.

The snowball sampling via the Society of Hospital Medicine committees may not have yielded a representative sample of female hospitalists. It seems possible that women who are involved in this type of leadership may be better supported and/or have different work schedules than their peers who are not in leadership positions. We also wish there had been more emphasis on the systemic and structural factors that can improve the quality of life of physician mothers. These policies include paternity leave and other creative ways of acknowledging the useful skills and experience that motherhood brings to bear on clinical practice, such as increased empathy and compassion, as mentioned by one of the study participants.

Even with the aforementioned limitations, this study is important because it combines authentic quotes from practicing academic hospitalists with concrete and tangible suggestions for structural changes. The most striking element is that the majority of the study participants experienced uncertainty and a lack of transparency around parental leave policies. As nearly half of hospitalists are women and 80% are under age 40,² it seems unimaginable that there would not be explicit policies in place for what is a common and largely anticipated life event. Medicine has made great strides toward gender equality, but we are unlikely to ever reach the goal of true parity without openly addressing the disproportionate effect of childbearing and child rearing on women physicians. Standardized, readily available, and equitable parental leave policies (for both birth parents and nonbirth parents) are the first and most critical step.

The absence of standard leave policies naturally puts physician mothers in the position of having to negotiate or “haggle” with various supervisors, the majority of whom are male division chiefs and department chairs,³ which places all parties in an uncomfortable position, further reinforcing inequities and sowing discord and resentment. Having formal policies around leave protects not only those who utilize parental leave but also the other members of a hospital medicine practice who take on the workload of the person on leave.

Uncertainty around how to address the increased clinical load and for how long, also creates anxiety among other group members and may lead to feelings of bitterness toward clinicians on leave, further contributing to the negative impact of new parenthood on female hospitalists. We can think of no other medical circumstance in which there is as much advance notice of the need for significant time away from work. Yet pregnancy, which is subject to complications and emergencies just like other medical conditions, is treated with so little concern that one may be asked to arrange for their own coverage during such an emergency, as one study subject reported.

We also empathize with the study participants’ reports of feeling that supervisors often mentally discounted their ability to participate in projects on return to work. These pernicious assumptions can compound a cycle of lost productivity, disengagement, and attrition from the workforce.

Female hospitalists returning from leave face additional challenges that place an undue burden on their professional activities, most notably related to breastfeeding. This is particularly relevant in the context of the intensity inherent in practicing hospital medicine, which includes long days of being the primary provider for acutely ill inpatients, as well as long stretches of many consecutive days when it may not be possible to return home before children’s bedtime. Even at our own institution, which has been recognized as a “Healthy Mothers Workplace,” breastfeeding accommodations are not set up to allow for ongoing clinical activities while taking time to express breastmilk, and the clinical schedule does not build in adjustments for this time-consuming and psychologically taxing commitment. Breastfeeding for at least one year is the medical recommendation of the American Academy of Pediatrics in line with a substantial body of evidence.⁴ One quote from the article poignantly notes, “Pumping every 3-4 hours: stopping what you’re doing, finding an empty room to pump, finding a place to store your milk, then going back to work, three times per shift, for the next 9 months of your life, was hell.” If we cannot enable our own medical providers to follow evidence-based recommendations, how can we possibly expect this of our patients?

The notion of women “having it all” is an impossible ideal—both work and life outside of work will inevitably require tradeoffs. However, there is an abundance of evidence and recommendations for concrete steps that can be taken to improve the experience of female physicians who have children. These include formal policies for childbearing and child rearing leave (the American Academy of Pediatrics recommends at least six to nine months⁵), convenient space and protected time for pumping milk during the first year, on-site childcare services and back-up child care, and flexible work schedules.⁶ It is time to stop treating childbirth among female physicians like an unexpected inconvenience and acknowledge the undeniable demographics of physicians in hospital medicine and the duty of healthcare systems and hospital medicine leaders to effectively plan for the needs of half of their workforce.

Disclosures

Neither of the authors have any financial conflicts of interest to disclose.

In this month’s edition of the Journal of Hospital Medicine, Goodwin and colleagues report their findings from their systematic review of models of care for frequently hospitalized patients. The authors reviewed the literature for interventions to reduce hospital admissions in frequently hospitalized patients with the goal of assessing the success of the interventions. This report contributes to the literature base of interventions to reduce healthcare utilization, particularly in the area of inpatient hospitalization.¹

Goodwin et al. report that only nine studies met their criteria for review after a thorough search of the published literature. Of these nine studies, only four were determined to be high-quality studies. Interestingly, the low-quality studies found positive results in reducing hospital utilization, whereas the high-quality studies found decreases that were mirrored by their control groups. Impressive heterogeneity was found in the range of definitions, interventions, and outcome measures in the studies. These studies highlight the issue of “regression to the mean” for sicker individuals; however, they may not address readmission rates of specific medical systems or procedures that are also cost drivers, even if the patients are not considered critically ill. They also show where research partnerships can assist in increasing the number of members included in the studies for robust analyses.

 From the perspective of a health plan, we applaud all efforts to improve patient outcomes and reduce cost. This report states that efforts to reduce chronic hospitalizations have not been unqualified successes. We must reflect upon how reducing utilization and improving outcomes align with our overall goals as a society. Recently, Federal Reserve Chairman Jay Powell summed up our nation’s particular issue, stating, “It is widely understood that the United States is on an unsustainable fiscal path, largely due to the interaction between an aging population and a healthcare system that delivers pretty average healthcare at a cost that is much higher than that of any other advanced economy.”²

A recent Kaiser Family Foundation analysis showed that 1% of patients accounted for 23% of all medical spending in the United States, and 97% of medical spending is attributed to the top 50% of patients.³ Pharmaceutical costs also play a role in this trend. Blue Cross and Blue Shield of Texas (BCBSTX) found that 2.5% of our population accounted for just under 50% of total medical spending. Conversely, when looking at patients with very high costs, only 0.4% had over $100,000 in spending exclusive of pharmacy. When including pharmacy, that number rises to 0.5%. As we consider annual medical and pharmacy trends year over year, we find that pharmacy spending may outpace hospital expenses in the near future.

Our internal data are also consistent with published reports that fewer than half of high-cost patients in one year continue to be high-cost cases the following year. Niall Brennan et al. reported that only 39% of the top 5% of spenders in a given year are also high spenders the following year.⁴ This finding not only coincides with the author’s statement around regression to the mean for the high admission utilizers, but it may be instructive to those looking to a Pareto method of attacking cost. If more than half of targeted patients will move out of the high cost category on their own, then demonstrating the effectiveness of interventions becomes challenging. Moreover, this regression finding speaks to the need to create effective programs to manage population health on a broad basis, which can address quality to all members and streamline costs for a large group that covers well more than 50% of medical spending.

BCBSTX emphasizes the creation of systems that let providers become responsible and accountable to outcomes and cost. Accountable Care Organizations (ACOs) and Intensive Medical Homes (IMHs) have played important roles in this journey, but physicians need to continue to invent and prioritize interventions that may achieve both goals. In particular, hospitalists have an important role to play. As ACOs flourish, hospitalists will need to join under the value-based umbrella and continue to intervene in patient care, policies, and procedures to reduce avoidable hospitalizations.

The development of value-based arrangements offers the healthcare system a unique opportunity to bring much-needed change. In our medical partnerships, direct communication with providers regarding their member experience and sharing of vital information about their patients’ health status have helped improve patient outcomes and decrease cost. Our IMH partnerships show a savings of up to $45,000 per member per year driven by decreases in admissions and ER visits, and in some cases, expensive medications. The hard work in these successes lies within the subtleties of fostering the relationship between payers and providers. Each pillar within the ecosystem plays a key role offering strengths, but the upside toward change comes in how we support each other’s weaknesses. This support is manifested in two ways: collaboration through communication and transparency through data sharing.

The road to change is one less traveled but not unpaved; advances in technology allow us to take experiences and build from them. At its core, technology has enhanced our collaboration and data capabilities. The ability to stay in touch with providers allows for almost real-time addressing of issues, promoting efficiency. The connection we have with providers has evolved from being solely paper contracts to a multichannel, multifunctional system. The ability to take claims experience, insert clinical acumen, and perform data analysis brings actionable solutions to be executed by our providers.

Those in the healthcare system will need to come together to continue to create interventions that improve quality while decreasing costs. The second part may require even more work than the first. The Health Care Cost Institute recently published data showing that inpatient utilization over a five-year period fell 12.9% in the commercially insured.⁵ However, over that same period, hospital prices for inpatient care rose 24.3%. The fundamental reason for the excess amount of money spent in US healthcare is that the prices are incredibly high.⁶ Currently, when diligence is exercised in reducing utilization, hospitals simply raise prices as a response to compensate for the lost income. Likewise, although prescription drug utilization only increased 1.8% during that period, the prices increased by 24.9%.

For the United States healthcare system to improve its quality and reduce its cost, we will need inventive partnerships to continue to create new systems to interact with patients in the most efficient and effective way possible. Readmissions and hospital utilization will be a large part of that improvement. Hospitals and hospitalists should ensure that they continue to focus on making healthcare more affordable by improving efficiency and outcomes and by resisting the tendencies of hospitals and pharmaceutical companies to raise prices in reaction to the improved efficiency.

Disclosures

The authors have nothing to disclose.

In this month’s edition of the Journal of Hospital Medicine, Goodwin and colleagues report their findings from their systematic review of models of care for frequently hospitalized patients. The authors reviewed the literature for interventions to reduce hospital admissions in frequently hospitalized patients with the goal of assessing the success of the interventions. This report contributes to the literature base of interventions to reduce healthcare utilization, particularly in the area of inpatient hospitalization.¹

Goodwin et al. report that only nine studies met their criteria for review after a thorough search of the published literature. Of these nine studies, only four were determined to be high-quality studies. Interestingly, the low-quality studies found positive results in reducing hospital utilization, whereas the high-quality studies found decreases that were mirrored by their control groups. Impressive heterogeneity was found in the range of definitions, interventions, and outcome measures in the studies. These studies highlight the issue of “regression to the mean” for sicker individuals; however, they may not address readmission rates of specific medical systems or procedures that are also cost drivers, even if the patients are not considered critically ill. They also show where research partnerships can assist in increasing the number of members included in the studies for robust analyses.

 From the perspective of a health plan, we applaud all efforts to improve patient outcomes and reduce cost. This report states that efforts to reduce chronic hospitalizations have not been unqualified successes. We must reflect upon how reducing utilization and improving outcomes align with our overall goals as a society. Recently, Federal Reserve Chairman Jay Powell summed up our nation’s particular issue, stating, “It is widely understood that the United States is on an unsustainable fiscal path, largely due to the interaction between an aging population and a healthcare system that delivers pretty average healthcare at a cost that is much higher than that of any other advanced economy.”²

A recent Kaiser Family Foundation analysis showed that 1% of patients accounted for 23% of all medical spending in the United States, and 97% of medical spending is attributed to the top 50% of patients.³ Pharmaceutical costs also play a role in this trend. Blue Cross and Blue Shield of Texas (BCBSTX) found that 2.5% of our population accounted for just under 50% of total medical spending. Conversely, when looking at patients with very high costs, only 0.4% had over $100,000 in spending exclusive of pharmacy. When including pharmacy, that number rises to 0.5%. As we consider annual medical and pharmacy trends year over year, we find that pharmacy spending may outpace hospital expenses in the near future.

Our internal data are also consistent with published reports that fewer than half of high-cost patients in one year continue to be high-cost cases the following year. Niall Brennan et al. reported that only 39% of the top 5% of spenders in a given year are also high spenders the following year.⁴ This finding not only coincides with the author’s statement around regression to the mean for the high admission utilizers, but it may be instructive to those looking to a Pareto method of attacking cost. If more than half of targeted patients will move out of the high cost category on their own, then demonstrating the effectiveness of interventions becomes challenging. Moreover, this regression finding speaks to the need to create effective programs to manage population health on a broad basis, which can address quality to all members and streamline costs for a large group that covers well more than 50% of medical spending.

BCBSTX emphasizes the creation of systems that let providers become responsible and accountable to outcomes and cost. Accountable Care Organizations (ACOs) and Intensive Medical Homes (IMHs) have played important roles in this journey, but physicians need to continue to invent and prioritize interventions that may achieve both goals. In particular, hospitalists have an important role to play. As ACOs flourish, hospitalists will need to join under the value-based umbrella and continue to intervene in patient care, policies, and procedures to reduce avoidable hospitalizations.

The development of value-based arrangements offers the healthcare system a unique opportunity to bring much-needed change. In our medical partnerships, direct communication with providers regarding their member experience and sharing of vital information about their patients’ health status have helped improve patient outcomes and decrease cost. Our IMH partnerships show a savings of up to $45,000 per member per year driven by decreases in admissions and ER visits, and in some cases, expensive medications. The hard work in these successes lies within the subtleties of fostering the relationship between payers and providers. Each pillar within the ecosystem plays a key role offering strengths, but the upside toward change comes in how we support each other’s weaknesses. This support is manifested in two ways: collaboration through communication and transparency through data sharing.

The road to change is one less traveled but not unpaved; advances in technology allow us to take experiences and build from them. At its core, technology has enhanced our collaboration and data capabilities. The ability to stay in touch with providers allows for almost real-time addressing of issues, promoting efficiency. The connection we have with providers has evolved from being solely paper contracts to a multichannel, multifunctional system. The ability to take claims experience, insert clinical acumen, and perform data analysis brings actionable solutions to be executed by our providers.

Those in the healthcare system will need to come together to continue to create interventions that improve quality while decreasing costs. The second part may require even more work than the first. The Health Care Cost Institute recently published data showing that inpatient utilization over a five-year period fell 12.9% in the commercially insured.⁵ However, over that same period, hospital prices for inpatient care rose 24.3%. The fundamental reason for the excess amount of money spent in US healthcare is that the prices are incredibly high.⁶ Currently, when diligence is exercised in reducing utilization, hospitals simply raise prices as a response to compensate for the lost income. Likewise, although prescription drug utilization only increased 1.8% during that period, the prices increased by 24.9%.

For the United States healthcare system to improve its quality and reduce its cost, we will need inventive partnerships to continue to create new systems to interact with patients in the most efficient and effective way possible. Readmissions and hospital utilization will be a large part of that improvement. Hospitals and hospitalists should ensure that they continue to focus on making healthcare more affordable by improving efficiency and outcomes and by resisting the tendencies of hospitals and pharmaceutical companies to raise prices in reaction to the improved efficiency.

Disclosures

The authors have nothing to disclose.

In this month’s edition of the Journal of Hospital Medicine, Goodwin and colleagues report their findings from their systematic review of models of care for frequently hospitalized patients. The authors reviewed the literature for interventions to reduce hospital admissions in frequently hospitalized patients with the goal of assessing the success of the interventions. This report contributes to the literature base of interventions to reduce healthcare utilization, particularly in the area of inpatient hospitalization.¹

Goodwin et al. report that only nine studies met their criteria for review after a thorough search of the published literature. Of these nine studies, only four were determined to be high-quality studies. Interestingly, the low-quality studies found positive results in reducing hospital utilization, whereas the high-quality studies found decreases that were mirrored by their control groups. Impressive heterogeneity was found in the range of definitions, interventions, and outcome measures in the studies. These studies highlight the issue of “regression to the mean” for sicker individuals; however, they may not address readmission rates of specific medical systems or procedures that are also cost drivers, even if the patients are not considered critically ill. They also show where research partnerships can assist in increasing the number of members included in the studies for robust analyses.

 From the perspective of a health plan, we applaud all efforts to improve patient outcomes and reduce cost. This report states that efforts to reduce chronic hospitalizations have not been unqualified successes. We must reflect upon how reducing utilization and improving outcomes align with our overall goals as a society. Recently, Federal Reserve Chairman Jay Powell summed up our nation’s particular issue, stating, “It is widely understood that the United States is on an unsustainable fiscal path, largely due to the interaction between an aging population and a healthcare system that delivers pretty average healthcare at a cost that is much higher than that of any other advanced economy.”²

A recent Kaiser Family Foundation analysis showed that 1% of patients accounted for 23% of all medical spending in the United States, and 97% of medical spending is attributed to the top 50% of patients.³ Pharmaceutical costs also play a role in this trend. Blue Cross and Blue Shield of Texas (BCBSTX) found that 2.5% of our population accounted for just under 50% of total medical spending. Conversely, when looking at patients with very high costs, only 0.4% had over $100,000 in spending exclusive of pharmacy. When including pharmacy, that number rises to 0.5%. As we consider annual medical and pharmacy trends year over year, we find that pharmacy spending may outpace hospital expenses in the near future.

Our internal data are also consistent with published reports that fewer than half of high-cost patients in one year continue to be high-cost cases the following year. Niall Brennan et al. reported that only 39% of the top 5% of spenders in a given year are also high spenders the following year.⁴ This finding not only coincides with the author’s statement around regression to the mean for the high admission utilizers, but it may be instructive to those looking to a Pareto method of attacking cost. If more than half of targeted patients will move out of the high cost category on their own, then demonstrating the effectiveness of interventions becomes challenging. Moreover, this regression finding speaks to the need to create effective programs to manage population health on a broad basis, which can address quality to all members and streamline costs for a large group that covers well more than 50% of medical spending.

BCBSTX emphasizes the creation of systems that let providers become responsible and accountable to outcomes and cost. Accountable Care Organizations (ACOs) and Intensive Medical Homes (IMHs) have played important roles in this journey, but physicians need to continue to invent and prioritize interventions that may achieve both goals. In particular, hospitalists have an important role to play. As ACOs flourish, hospitalists will need to join under the value-based umbrella and continue to intervene in patient care, policies, and procedures to reduce avoidable hospitalizations.

The development of value-based arrangements offers the healthcare system a unique opportunity to bring much-needed change. In our medical partnerships, direct communication with providers regarding their member experience and sharing of vital information about their patients’ health status have helped improve patient outcomes and decrease cost. Our IMH partnerships show a savings of up to $45,000 per member per year driven by decreases in admissions and ER visits, and in some cases, expensive medications. The hard work in these successes lies within the subtleties of fostering the relationship between payers and providers. Each pillar within the ecosystem plays a key role offering strengths, but the upside toward change comes in how we support each other’s weaknesses. This support is manifested in two ways: collaboration through communication and transparency through data sharing.

The road to change is one less traveled but not unpaved; advances in technology allow us to take experiences and build from them. At its core, technology has enhanced our collaboration and data capabilities. The ability to stay in touch with providers allows for almost real-time addressing of issues, promoting efficiency. The connection we have with providers has evolved from being solely paper contracts to a multichannel, multifunctional system. The ability to take claims experience, insert clinical acumen, and perform data analysis brings actionable solutions to be executed by our providers.

Those in the healthcare system will need to come together to continue to create interventions that improve quality while decreasing costs. The second part may require even more work than the first. The Health Care Cost Institute recently published data showing that inpatient utilization over a five-year period fell 12.9% in the commercially insured.⁵ However, over that same period, hospital prices for inpatient care rose 24.3%. The fundamental reason for the excess amount of money spent in US healthcare is that the prices are incredibly high.⁶ Currently, when diligence is exercised in reducing utilization, hospitals simply raise prices as a response to compensate for the lost income. Likewise, although prescription drug utilization only increased 1.8% during that period, the prices increased by 24.9%.

For the United States healthcare system to improve its quality and reduce its cost, we will need inventive partnerships to continue to create new systems to interact with patients in the most efficient and effective way possible. Readmissions and hospital utilization will be a large part of that improvement. Hospitals and hospitalists should ensure that they continue to focus on making healthcare more affordable by improving efficiency and outcomes and by resisting the tendencies of hospitals and pharmaceutical companies to raise prices in reaction to the improved efficiency.

Disclosures

The authors have nothing to disclose.