RIV Competition 200 Abstracts

86 research abstracts that identify innovative research areas specific to our specialty

Research Co-chairs:– Vineet Arora, MD, MA

University of Chicago

– Margaret Fang, MD, MPH University of California at San Francisco

RIV Competition: 40 Innovations 65 Clinical Vignettes

Innovations Co-chairs– Jeffrey Greenwald, MD, Boston University School of

Medicine– Jennifer S. Myers, MD, University of Pennsylvania

Clinical Vignettes Co-chairs– Aaron Kalyanasundaram, MD

Geisinger Medical Center– Christopher Whinney, MD

Cleveland Clinic Foundation

Safe S.T.E.Ps.Safe & Successful Transition of Elderly Patients

Param Dedhia MD1, Eric Howell MD1, Steve Kravet MD1, John Bulger DO2, Tony Hinson MD3, & Scott Wright, MD1

Johns Hopkins Bayview Medical Center 1

Geisinger Medical Center 2

NorthEast Medical Center 3

Funded by John A. Hartford Foundation and Society of Hospital Medicine

Hospitals and the Elderly

• Overarching goal in caring for older patients

– Avoid Hospitals

– Address the issues related to peri-discharge • 49% of patients experience 1 medical error(s)• 19-23% suffer adverse events

• Transition of elderly from hospital to home requires additional attention & research

Forster, CMAJ. 2004;170:345-349. Forster, Ann Intern Med. 2003;138:161-7. Moore C,. JGIM. 2003;18:646-651.

Hypothesis

1. Interdisciplinary, multifaceted intervention could improve the transition of older adults from hospital to home

2. Such an intervention could work and be feasible at different types of hospitals

Objectives

1. To develop an interdisciplinary intervention– toolkit

2. To evaluate the toolkit & determine its impact on:

a. Patient satisfaction with discharge process

b. Objective healthcare outcomes • ED revisit rate• Hospital readmission rate

Methods

Study Design: • Pre (control) vs. Post (intervention)

Setting: • General Medicine Wards at 3 medical centers

• Service staffed by hospitalist groups

Inclusion Criteria:

• Age 65 years

• ‘Home’ as planned discharge disposition

Exclusion Criteria:

• Anticipation of death during the hospitalization

• Admission & discharge within same weekend

Data Collection:

• (i) Admission

• (ii) Day 3 post discharge

• (iii) Day 30 post discharge

Methods

Study Design: • Pre (control) vs. Post (intervention)

Setting: • General Medicine Wards at 3 medical centers

• Service staffed by hospitalist groups

Inclusion Criteria:

• Age 65 years

• ‘Home’ as planned discharge disposition

Exclusion Criteria:

• Anticipation of death during the hospitalization

• Admission & discharge within same weekend

Data Collection:

• (i) Admission

• (ii) Day 3 post discharge

• (iii) Day 30 post discharge

Methods

Study Design: • Pre (control) vs. Post (intervention)

Setting: • General Medicine Wards at 3 medical centers

• Service staffed by hospitalist groups

Inclusion Criteria:

• Age 65 years

• ‘Home’ as planned discharge disposition

Exclusion Criteria:

• Anticipation of death during the hospitalization

• Admission & discharge within same weekend

Data Collection:

• (i) Admission

• (ii) Day 3 post discharge

• (iii) Day 30 post discharge

Methods

Study Design: • Pre (control) vs. Post (intervention)

Setting: • General Medicine Wards at 3 medical centers

• Service staffed by hospitalist groups

Inclusion Criteria:

• Age 65 years

• ‘Home’ as planned discharge disposition

Exclusion Criteria:

• Anticipation of death during the hospitalization

• Admission & discharge within same weekend

Data Collection:

• (i) Admission

• (ii) Day 3 post discharge

• (iii) Day 30 post discharge

Methods

Study Design: • Pre (control) vs. Post (intervention)

Setting: • General Medicine Wards at 3 medical centers

• Service staffed by hospitalist groups

Inclusion Criteria:

• Age 65 years

• ‘Home’ as planned discharge disposition

Exclusion Criteria:

• Anticipation of death during the hospitalization

• Admission & discharge within same weekend

Data Collection:

• (i) Admission

• (ii) Day 3 post discharge

• (iii) Day 30 post discharge

Methods

Study Design: • Pre (control) vs. Post (intervention)

Setting: • General Medicine Wards at 3 medical centers

• Service staffed by hospitalist groups

Inclusion Criteria:

• Age 65 years

• ‘Home’ as planned discharge disposition

Exclusion Criteria:

• Anticipation of death during the hospitalization

• Admission & discharge within same weekend

Data Collection:

• (i) Admission

• (ii) Day 3 post discharge

• (iii) Day 30 post discharge

Components of Intervention

1. “Geriatricized” H&P - Cues & prompts to care of older patient

2. Fast Facts Fax - Focused communication to primary provider

3. Interdisciplinary Team Worksheet

- Central location for input from all disciplines

4. Medication Evaluation

- Detailed medication review with pharmacist

5. Pre-Discharge Appointment

- Meeting of patient, caregiver & provider to

review the hospital course & discharge

Components of Intervention

1. “Geriatricized” H&P - Cues & prompts to care of older patient

2. Fast Facts Fax - Focused communication to primary provider

3. Interdisciplinary Team Worksheet

- Central location for input from all disciplines

4. Medication Evaluation

- Detailed medication review with pharmacist

5. Pre-Discharge Appointment

- Meeting of patient, caregiver & provider to

review the hospital course & discharge

Components of Intervention

1. “Geriatricized” H&P - Cues & prompts to care of older patient

2. Fast Facts Fax - Focused communication to primary provider

3. Interdisciplinary Team Worksheet

- Central location for input from all disciplines

4. Medication Evaluation

- Detailed medication review with pharmacist

5. Pre-Discharge Appointment

- Meeting of patient, caregiver & provider to

review the hospital course & discharge

Components of Intervention

1. “Geriatricized” H&P - Cues & prompts to care of older patient

2. Fast Facts Fax - Focused communication to primary provider

3. Interdisciplinary Team Worksheet

- Central location for input from all disciplines

4. Medication Evaluation

- Detailed medication review with pharmacist

5. Pre-Discharge Appointment

- Meeting of patient, caregiver & provider to

review the hospital course & discharge

Components of Intervention

1. “Geriatricized” H&P - Cues & prompts to care of older patient

2. Fast Facts Fax - Focused communication to primary provider

3. Interdisciplinary Team Worksheet

- Central location for input from all disciplines

4. Medication Evaluation

- Detailed medication review with pharmacist

5. Pre-Discharge Appointment

- Meeting of patient, caregiver & provider to

review the hospital course & discharge

Components of Intervention

1. “Geriatricized” H&P - Cues & prompts to care of older patient

2. Fast Facts Fax - Focused communication to primary provider

3. Interdisciplinary Team Worksheet

- Central location for input from all disciplines

4. Medication Evaluation

- Detailed medication review with pharmacist

5. Pre-Discharge Appointment

- Meeting of patient, caregiver & provider to

review the hospital course & discharge

ResultsControl (N = 237) Study (N = 185) p

• Age, mean (SD) 77.30 (6.98) 76.66 (7.67) 0.381

• Female, n (%) 143 (60.34) 113 (61.75) 0.770

• ADLs, mean (SD) 0.47 (0.10) 0.50 (0.11) 0.825

• Prescriptions, mean (SD) 6.83 (4.32) 7.28 (3.79) 0.270

• Intervention had higher rates of following (all p < 0.05) :

− Obesity − Falls − Reading limited by eyesight

− Anti-hypertensive

Medicines

− Fractures − Living alone

− Cancer

ResultsControl (N = 237) Study (N = 185) p

• Age, mean (SD) 77.30 (6.98) 76.66 (7.67) 0.381

• Female, n (%) 143 (60.34) 113 (61.75) 0.770

• ADLs, mean (SD) 0.47 (0.10) 0.50 (0.11) 0.825

• Prescriptions, mean (SD) 6.83 (4.32) 7.28 (3.79) 0.270

• Intervention had higher rates of following (all p < 0.05) :

− Obesity − Falls − Reading limited by eyesight

− Anti-hypertensive

Medicines

− Fractures − Living alone

− Cancer

Satisfaction with Transition from Hospital to Home

010

203040

50607080

90100

CTM-3 CTM-15

CT

M s

core

s ab

ove

72 (

%)

**

p < 0.001*

Control

Study

Satisfaction with Transition from Hospital to Home

010

203040

50607080

90100

CTM-3 CTM-15

CT

M s

core

s ab

ove

72 (

%)

**

p < 0.001*

Control

Study

Health Assessment by Self Report

0102030405060708090

100

3 Day 30 Day

% B

ette

r T

ha

n B

efo

re H

osp

ital

* ‡

p = 0.003, ‡ p = 0.001*

Control

Study

3 Day ED Revisits or Readmission

OR = 0.25 (0.10-0.62) p < 0.003

0

2

4

6

8

10

12

ED Revisit andReadmission

Ra

te (

%)

*

*

Control

Study

30 day ED Revisits or Readmission

OR = 0.58 (0.34 - 0.99) OR = 0.55 (0.32 - 0.55)

p = 0.046 p = 0.029

0

5

10

15

20

25

ED Revisit Readmission

Rat

e (%

)

* ‡

* ‡

Control

Study

Conclusion

• The Safe STEPs Toolkit positively impacted upon the transition from hospital to home among older adults

– Improved Patient Satisfaction

– Decreased ED & Readmission Rates

Limitations

• Pre-post study

• Seasonal variation

Implications & Next Steps

• Identify those at greatest risk of poor transition – Resources and attention to be focused

• Tailoring the toolkit to fit the needs of specific hospitals and hospitalist groups

29Confidential

The Impact of Fragmentation of Hospitalist Care on Length of Stay

and Post-Discharge Issues

Epstein KR, Juarez E, Epstein A, Loya K, Singer A.

30Confidential

BACKGROUND BACKGROUND

The majority of the discussion around hospitalist staffing models has related to the impact on the physicians.

Much less discussion on impact of different hospitalist staffing models on inpatient continuity of care.

Little known about the impact of discontinuity of care on length of stay (LOS) and other utilization and quality metrics.

The purpose of this study was to explore the impact of continuity of hospitalist staffing patterns on acute care length of stay and on clinical problems post-discharge.

31Confidential

METHOD METHOD Using IPC’s billing and clinical database, we analyzed

all inpatient admissions between 12/06 and 11/07 for:– DRG 89: Pneumonia with complications or

comorbidities– DRG 127: Heart failure and shock.

Fragmentation of Care (FOC): Defined as the percentage of care given by hospitalists other than the hospitalist who saw the patient the majority of the stay (defined as the primary hospitalist).

Examples:– If 100% of care provided by 1 physician, FOC would be

0%– If patient hospitalized 5 days, cared for by one doctor 3

days (primary hospitalist), other doctors other 2 days, then FOC = 2/5 = 40%.

– If patient hospitalized 7 days, cared for by one doctor 5 days (primary hospitalist), another doctor 2 day, then FOC = 2/7 = 28.5%.

32Confidential

METHODMETHOD

Ordinary least squares (OLS) regressions were performed separately on DRG 89 and DRG 127 patients with LOS as the dependent variable.

Independent variables: gender, age, severity of illness scores, risk of mortality scores, and the number of secondary diagnoses.

For a subset of patients, we had data from surveys performed 48-72 hours post-discharge by our call center. Logistic regressions were performed on the combined diagnoses group with reported problems requiring nurse follow up as the dependent variables.

33Confidential

STUDY POPULATIONSTUDY POPULATION

We analyzed 10,233 patients with LOS < 14 days.– 1724 patients with DRG 89

– 8509 patients with DRG 127

Analyzed 2445 patients (combined DRGs) with post discharge call data

223 hospitals

16 states

34Confidential

CHARACTERISTICS OF STUDY POPULATION

DRG 89 (N=1724) DRG 127 (N=8509)

Mean (STD) Mean (STD)

Percent of Care by Non-Primary Hospitalist 20.2% (19.8) 17.6% (19.7)

Number of Physicians Seen During Hospital Stay

1.87 (.91) 1.69 (.82)

Needed Any Nurse Follow-up Post-Discharge

17.9% 20.8%

Medication Issues 5.1% 6.7%

Access to Care Issues 4.3% 3.9%

New or Worse Symptoms 8.5% 8.4%

Age 65.9 (18.6) 71.4 (15.3)

Severity of Illness 2.79 (.55) 1.92 (.70)

Risk of Mortality 2.45 (.83) 1.79 (.73)

Number of Secondary Diagnoses 5.5 (2.5) 4.9 (2.2)

35Confidential

Dependent Variable Fragmentation

Coefficient/ Odds Ratio

95% Confidence Interval

P-Value

LOS DRG 89 4.52 (3.79 – 5.26) P < .01

LOS DRG 127 3.81 (3.51 – 4.11) P < .01

Needed Nurse Follow-up 1.24 (.75 – 2.04) P = .40

Medication Follow-up 1.20 (.53 – 2.73) P = .66

Access to Care 2.48 (.92 – 6.70) P = .07

Symptoms need Follow-up 1.28 (.62 – 2.62) P = .51

ANALYSIS OF IMPACT OF FRAGMENTATION

36Confidential

RESULTS RESULTS

For every 10% increase in percent fragmentation, the LOS went up by 0.45 days for DRG 89, and 0.38 days for DRG 127 (both p< 0.0001).

There was no statistically significant change in post-discharge complications with increasing fragmentation of care.– The only complication that approached statistical

significance was the follow-up appointment group, where there was a 24.8% increase in problems with each 10% increase in fragmentation.

37Confidential

Ad

justed

LO

S

DRG 89 – Adjusted LOS by Fragmentation LevelDRG 89 – Adjusted LOS by Fragmentation Level

N=711

N=281N=271

N=305N=233

N=74 N=63 N=12

0

1

2

3

4

5

6

7

8

9

0-10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80%

Percentage of care by hospitalists other than primary hospitalist

DRG 89 - Adjusted LOS by Fragmentation Level

38Confidential

Ad

justed

LO

S

DRG 127 – Adjusted LOS by Fragmentation Level

N=4253

N=972 N=1010 N=1380N=984

N=232N=148

N=34N=2

0

1

2

3

4

5

6

7

8

0-10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90%

Percentage of care by hospitalists other than primary hospitalist

DRG 127 - Adjusted LOS by Fragmentation Level

39Confidential

CONCLUSIONS CONCLUSIONS

As fragmentation of inpatient care increased for pneumonia and heart failure, the LOS increased significantly.

Limitation: – Direction of causality between LOS and Fragmentation of

Care.• Controlled for DRG, severity of illness, risk of mortality

index, number of secondary diagnoses.• At longer LOS, if seen by another hospitalist, FOC index

will be lower– Don’t differentiate # of doctors caring for pt. other than primary

hospitalist

Future Studies:– Look at impact of practice/staffing models on FOC and LOS. – Explore impact of fragmentation occurring at point of

admission, discharge, or mid-stay.– Explore other methods of calculating FOC measures.

The Mayo Clinic Arizona The Mayo Clinic Arizona Post-Graduate PA Post-Graduate PA Fellowship in Hospital Fellowship in Hospital Internal MedicineInternal Medicine

Kristen K. Will, MHPE, PA-CKristen K. Will, MHPE, PA-CCo-Program Director, Co-Program Director, Mayo Clinic Arizona Hospitalist PA Fellowship ProgramMayo Clinic Arizona Hospitalist PA Fellowship ProgramInstructor, Mayo Clinic College of MedicineInstructor, Mayo Clinic College of MedicineSHM Annual Conference, SHM Annual Conference, San Diego, 2008San Diego, 2008

BackgroundBackgroundMid-level Provider Mid-level Provider DemandDemand Approximately 15% of hospitalist Approximately 15% of hospitalist

groups utilize physician assistantsgroups utilize physician assistants

Increased need to hire mid-level Increased need to hire mid-level providers:providers:– Shortage of hospitalist physiciansShortage of hospitalist physicians– ACCME resident hour restrictionsACCME resident hour restrictions– Team approach/patient continuityTeam approach/patient continuity– Augment medical resident educationAugment medical resident education

BackgroundBackgroundMid-level Provider SupplyMid-level Provider Supply

Difficult to find PA’s with hospitalist Difficult to find PA’s with hospitalist experience:experience:– New graduatesNew graduates– Recruitment of PA’s in subspecialitiesRecruitment of PA’s in subspecialities

New recruits may take 6-12 months New recruits may take 6-12 months to function at maximal productivityto function at maximal productivity

>>

BackgroundBackgroundPhysician Assistant Physician Assistant EducationEducation Primary care is main focusPrimary care is main focus

All masters degree as of 2007All masters degree as of 2007

Trained in medical modelTrained in medical model

One year didactic; one year clinical rotationsOne year didactic; one year clinical rotations

More outpatient based rotations; LESS inpatient More outpatient based rotations; LESS inpatient rotationsrotations

Less previous medical exposure prior to PA Less previous medical exposure prior to PA training; younger age at matriculationtraining; younger age at matriculation

DescriptionDescriptionPost-graduate PA Post-graduate PA EducationEducation Over 40 programs in U.S.Over 40 programs in U.S.

Provide PA extra training in Provide PA extra training in subspecialty areasubspecialty area

Most programs one year after PA schoolMost programs one year after PA school

Recognized by Association of Post-Recognized by Association of Post-graduate PA Programs (APPAP) graduate PA Programs (APPAP)

PurposePurpose

““To create To create a post graduate training a post graduate training program in hospital medicine program in hospital medicine for physician assistants.” for physician assistants.”

DescriptionDescriptionMayo Clinic ArizonaMayo Clinic Arizona

Founded in 1987Founded in 1987 Currently:~ 250 staff physicians, 77 residentsCurrently:~ 250 staff physicians, 77 residents Two main sites: Two main sites:

– ClinicClinic– HospitalHospital

Numerous medical and allied health Numerous medical and allied health training programstraining programs– 3 PA fellowships3 PA fellowships

Areas of Focus: Transplant, Neurosciences, Areas of Focus: Transplant, Neurosciences, OncologyOncology

Three Shields: Patient care, Education, ResearchThree Shields: Patient care, Education, Research

DescriptionDescriptionMayo Clinic HospitalMayo Clinic Hospital Opened in 1998Opened in 1998 250 beds250 beds High tech work environmentHigh tech work environment

– Electronic records, digital x-rays, etc.Electronic records, digital x-rays, etc.– Computer physician/provider order Computer physician/provider order

entryentry– Patient simulation floorPatient simulation floor

24 hour/day 24 hour/day in-housein-house staff coverage staff coverage Closed hospital system; busy EDClosed hospital system; busy ED

DescriptionDescriptionMCA HIM PA FellowshipMCA HIM PA Fellowship

FirstFirst Hospital Internal Medicine (HIM) PA Hospital Internal Medicine (HIM) PA Fellowship in the countryFellowship in the country

Approved in Fall of 2006; First fellow began Approved in Fall of 2006; First fellow began October 2007October 2007

Academic year October 1 thru September Academic year October 1 thru September 3030thth

Recognized by Association Post-graduate Recognized by Association Post-graduate Physician Assistant Programs (APPAP)Physician Assistant Programs (APPAP)

DescriptionDescriptionMCA HIM PA FellowshipMCA HIM PA Fellowship

12 Month Program12 Month Program

1 Fellow/year1 Fellow/year

Certificate of completion from Mayo Certificate of completion from Mayo Clinic College of Medicine Clinic College of Medicine

Stipend, CME, health and malpractice Stipend, CME, health and malpractice benefits offeredbenefits offered

DescriptionDescriptionCurriculumCurriculum

Clinical RotationsClinical Rotations

Teaching ModulesTeaching ModulesDidactic InstructionDidactic Instruction

Based upon the SHM “Core Competencies”

Figure 1: Example of PA Fellow Rotation Schedule

Month 1Month 1 General Hospital Internal Medicine, Day serviceGeneral Hospital Internal Medicine, Day service (Core Didactic Focus: GI and Pulmonary)

Month 2Month 2 General Hospital Internal Medicine, Day serviceGeneral Hospital Internal Medicine, Day service(Core Didactic Focus: Nephrology and Neurology)

Month 3Month 3 General Medicine ConsultsGeneral Medicine Consults

Month 4Month 4 CardiologyCardiology

Month 5Month 5 General Hospital Internal Medicine Night ServiceGeneral Hospital Internal Medicine Night Service (Core Didactic Focus: Infectious Disease)

Month 6Month 6 Palliative MedicinePalliative Medicine – 2 wks. /– 2 wks. / Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation – 2 – 2 wks.wks.

Month 7Month 7 Interventional RadiologyInterventional Radiology (Elective I)(Elective I) / / Transplant MedicineTransplant Medicine (Elective II) (Elective II)

Month 8Month 8 General Hospital Internal Medicine, Day serviceGeneral Hospital Internal Medicine, Day service (Core Didactic Focus: Hematology/Oncology)

Month 9Month 9 General Hospital Internal Medicine, Night ServiceGeneral Hospital Internal Medicine, Night Service(Core Didactic Focus: Critical Care Medicine)

Month 10Month 10 Endocrinology & NutritionEndocrinology & Nutrition

Month 11Month 11 Stroke NeurologyStroke Neurology (Elective III) (Elective III)

Month 12Month 12 General Hospital Internal Medicine, Day serviceGeneral Hospital Internal Medicine, Day service

DescriptionDescriptionCurriculum – Teaching Curriculum – Teaching ModulesModules Medical ethicsMedical ethics Coding, billing and documentationCoding, billing and documentation Leadership and practice managementLeadership and practice management CommunicationCommunication Case management and social servicesCase management and social services Medical decision making and evidence-based medicineMedical decision making and evidence-based medicine Pharmacokinetics, drug safety, and Pharmacokinetics, drug safety, and

pharmacoeconomicspharmacoeconomics Quality assurance and patient safetyQuality assurance and patient safety Stroke managementStroke management Wound and ostomy careWound and ostomy care Infection controlInfection control Risk managementRisk management Writing and publicationWriting and publication

*Adapted from: Dressler, et. al. The core competencies in hospital medicine: Development and methodology.  Journal of Hospital Medicine. 2006;1:48-56.

Figure 3Example of Teaching Module Lesson

Plan

Objectives:

1. List the current areas of focus that the Joint Commissionidentifies as “new” patient safety goals for a hospital program for 2008.

2. List the components of the 8th Scope Initiative as foundin the CMS reporting requirements for hospital systems.

Method of Instruction (Clinical Application):

•Participation on institution Patient Safety Subcommittee•Online patient safety lectures•Reading assignments on patient safety topics•Written manuscript on patient safety topic(s) submitted to peer-reviewed journal•Practice and observation of patient safety in everyday clinical practice

Assessment Tools:

•Evaluation and completion of written manuscript•Completion of online lecture post-test with >90% pass rate.

Didactic Component

ClinicalApplication

Assessment

DescriptionDescriptionCurriculum - Curriculum - AssessmentAssessment End of rotation evaluations (12) End of rotation evaluations (12) End-year manuscript submitted for End-year manuscript submitted for

publication by peer-reviewed journal publication by peer-reviewed journal Mid-year and end-year formal Mid-year and end-year formal

comprehensive evaluations comprehensive evaluations Competency checklist of modules Competency checklist of modules

completed by end of fellowship training completed by end of fellowship training Journal club presentationsJournal club presentations Professional PortfolioProfessional Portfolio Teaching module assignmentsTeaching module assignments

ConclusionConclusionFuture GoalsFuture Goals Voluntary accreditation through Voluntary accreditation through

Accreditation Review Commission Accreditation Review Commission for Physician Assistants (ARC-PA)for Physician Assistants (ARC-PA)

Open to Nurse PractitionersOpen to Nurse Practitioners

Expand number of fellows per yearExpand number of fellows per year

ReferencesReferences

The SHM 2005-2006 Survey: The Authoritative The SHM 2005-2006 Survey: The Authoritative Source on the State of the Hospitalist Movement. Source on the State of the Hospitalist Movement. Pages 1-5.Pages 1-5.

Dubaybo, BA, Samson, MK, Carlson, RW. The role of Dubaybo, BA, Samson, MK, Carlson, RW. The role of physician assistants in critical care units. physician assistants in critical care units. ChestChest. . 1991;99:89-91.1991;99:89-91.

American Academy of Physician Assistants. 2006 American Academy of Physician Assistants. 2006 AAPA Census report. Available at AAPA Census report. Available at http://www.aapa.org/research/06census-intro.html. Ahttp://www.aapa.org/research/06census-intro.html. Accessed April 30,2007ccessed April 30,2007

Duffy, K. Physician assistants: Filling the gap in Duffy, K. Physician assistants: Filling the gap in patient care in academic hospitals. patient care in academic hospitals. Perspective on Perspective on Physician Assistant Education.Physician Assistant Education. 2003;14(3):158-167. 2003;14(3):158-167.

Dressler, et. al. Dressler, et. al. The core competencies in hospital medicine: DeveloThe core competencies in hospital medicine: Development and methodologypment and methodology.  .  Journal of Hospital Medicine.Journal of Hospital Medicine. 2006;1:48-56. 2006;1:48-56.