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Vol. 32

Num. 5

May 09

To Promote Improved

Patient Care, Research, and

Education in Primary Care and

General Internal Medicine

InspireInformConnect

CONTENTS

1. Editorial: Can I Fire My Hospitalist? . . . . . . . . . . . . . . .1

2. Essay: The Various Handoffs . . . . .2

3. President's Column . . . . . . . . . . . .3

4. How Do You Do That? . . . . . . . . . .4

5. Outpatient Morning Report . . . . . .6

6. Practice Innovations . . . . . . . . . . . .8

SGIMFORUMThe Society of General Internal Medicine

EDITORIAL

Can I Fire My Hospitalist?Robert Centor, MD

I received an email from a patient. He directed the email to mebecause I was quoted in the Wall Street Journal blog abouthospitalists.

He is a 49-year-old man with diabetes mellitus type II, CAD,CHF, and hypertension. He has an excellent relationship withhis internist and his cardiologist. Unfortunately, he stronglydislikes the hospitalist to whom he was assigned during twohospitalizations.

He wrote, “To me, my life is worth far more than themhaving to run a few tests and put me on a nitro drip. I am notsure if all hospitalists act in this manner, but to me thisparticular hospitalist does not treat all patients with appropriatemedical care, respect, and dignity—especially when he feels itconflicts with saving the IPA/HMO money. One thing I wish Iknew is: Do I have the right to essentially ‘fire’ this hospitalistso that he never has a hand in any future medical care I mayneed or get if I am a patient in this particular hospital?”

This patient raises a disturbing question. If this patient doesnot think that I am the proper internist, he can fire me and getanother internist. If he does not like the cardiologist, he can askfor another cardiologist. Does he have the same rights whendealing with hospitalists? I also wonder if some hospitalistprograms have an implicit conflict with patient preferences.

If you received this complaint and were heading ahospitalist program, how would you respond?

John Bulger, DOGeisinger

This is an infrequent yet real issue that our hospitalist group faces. Theshort answer is: The patient is always right. If patients want a differentphysician caring for them, that is their right, and we comply without ques-tion. As a teaching institution, the request may be for a change in thetreating hospitalist, resident, or physician assistant.

When a request is made, it is my philosophy that a change must be ad-dressed. A healthy and uninhibited patient-physician relationship is a criticalingredient for providing quality medical care. These requests usually comefrom the patient to either a treating provider, nurse, care managementagent, or patient liaison staffing the Action Line (24-hour patient concernhotline). The concern is then forwarded to the leadership of the hospital

continued on page 12

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out could come with little profile pic-tures of the patients in bed, I’d bevery happy. At my current practice, Ifeel we do quite well in followingmost of the handoff suggestions. Al-though I still have trouble fallingasleep on Sunday nights, at least Ihave an idea of what’s going on, whoto triage, etc., and I know that as theday progresses, I’ll be generating asatisfying, possibly even color-coded,series of check boxes for Tuesday.

Here’s what I really need a whitepaper on: the hospitalist-to-mommyhandoff. And not just the literal signout from our superb nanny, which isanother discussion altogether. I’mneither idealistic nor dumb enough tothink that at 5 pm—the prime witch-ing hour for two- and four-year-old fa-tigue—there will be time ortechnology for interruption-free, inter-active, insightful discussion of illevents or anticipated near-futuremelt downs. No, what I need instruc-tion on is how to mentally transitionfrom doctor mode to mom mode.From predictable and in control, forthe most part, to “if you give a childa kiss on the cheek, she’ll tell you itfeels funny and then she’ll want toshow you her boo-boo from schoolwhich will make her want to do anart project which will definitely makeher dirty and want to take a bathwhich will make her think of swim-ming and ask if we can go to thepool, the negative answer to whichwill make her cry, especially whenshe learns that vegetable chili iswhat’s for dinner.” (My daughterwonders why I like Laura Numeroff’sIf You Give A Cat A Cupcake chil-dren’s book so much. It’s just so verycomforting.)

I certainly don’t mean to implythat a physician’s career doesn’t ne-cessitate flexibility and reaction. Cer-tainly, the diagnostic detective workand the uniqueness of each patientkeep us going. But really, outside of

The hospitalist-to-hospitalist hand-off is a hot topic currently, andwith obvious good reason: As inpa-tient medicine becomes ever moreshift-work dependent, seamless tran-sitions of care are a must for patientsafety. How should it be standard-ized? What should it cover? Arethere outcomes data? Somewhatironically, the taskforce within the So-ciety of Hospital Medicine, after re-view of the literature and expertdiscussion, came up with “3T’s, 4I’s,and 3A’s” as the mnemonic for anadequate sign out. Reference to acerebrovascular event notwithstand-ing, their recommendations are cer-tainly logical and useful: Time,Template, Technology, and Training;Interruption-free, Interactive, Ill pa-tients, and Insight; Administrative-re-lated, Anticipated events, and Actionplans. In reality, the time one is will-ing to devote, and thus adhere, tothe described guideline continues tovary greatly. Personally, I tend to bethe type who wants to know it all, asin, “I’m sorry, but can you tell me ifthey’ve had their pneumovax and flushots yet, when their last BM was, iftheir hearing aids are working, andwhen they last spoke with theirgrandmother?” Honestly, if my sign

OFFICERS President

Lisa V. Rubenstein, MD, MSPH North Hills, CAlisar@rand.org (818) 891-7711

President ElectNancy A. Rigotti, MD Boston, MAnrigotti@partners.org (617) 724-4709

Immediate Past-PresidentEugene Rich, MD Omaha, NErichec@creighton.edu (202) 887-5150

TreasurerJeffrey Jackson, MD, MPH Bethesda, MDjejackson@usuhs.mil (202) 782-5603

SecretaryValerie Stone, MD, MPH Boston, MAvstone@partners.org (617) 726-7708

Secretary ElectMonica L. Lypson, MD Ann Arbor, MImlypson@med.umich.edu (734) 764-3186

COUNCIL

Marshall Chin, MD, MPHChicago, ILmchin@medicine.bsd.uchicago.edu (773) 702-4769

Karen DeSalvo, MD, MPH, MScNew Orleans, LAkdesalv@tulane.edu(504) 988-5473

Arthur G. Gomez, MDLos Angeles, CAartgomez@ucla.edu(818) 891--7711

Said A. Ibrahim, MD, MPHPittsburgh, PASaid.ibrahim@va.gov(412) 688-6477

Laura Sessums, MD, JDWashington, DCLaura.Sessums@us.army.mil(202) 782-5560

Donna L. Washington, MD, MPHLos Angeles, CAdonna.washington@va.gov(310) 478-3711 ext. 49479

Health Policy ConsultantLyle DennisWashington, DCldennis@dc-crd.com

Executive DirectorDavid Karlson, PhD2501 M Street, NW, Suite 575Washington, DC 20037KarlsonD@sgim.org(800) 822-3060; (202) 887-5150, 887-5405 Fax

Director of Communicationsand Publications

Francine JettonWashington, DCjettonf@sgim.org(202) 887-5150

EX OFFICIO COUNCIL MEMBERS

Regional CoordinatorDonald Brady, MD Atlanta, GAdbrady@emory.edu (404) 616-31171

ACGIM PresidentFrederick Brancati, MD, MHS Baltimore, MDfbrancat@jhmi.edu (410) 955-9843

Editors, Journal of General Internal MedicineMartha S. Gerrity, MD, PhD Portland, ORgerritym@ohsu.edu (503) 220-8262

Ext. 55592William M. Tierney, MD Indianapolis, INwtierney@iupui.edu (317) 630-6911

Editor, SGIM ForumRobert Centor, MD Birmingham, ALrcentor@uab.edu (205) 934-3007

Associate Member RepresentativeHannah E. Shacter St. Paul, MNhshacter@gmail.edu (612) 963-6813

ESSAY

The Various Handoffs: All a Learned Practice?Molly Emott, MD

Dr. Emott is an Academic Hospitalist at Fletcher Allen Health Care inBurlington, VT.

continued on page 7

SOCIETY OF GENERALINTERNAL MEDICINE

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One of the most painful issuesconfronting us as physicians,teachers, and researchers is our ownfallibility. On one level, we know that,as human beings, mistakes are partof the territory. As an esteemedelder colleague recently remarked ata meeting, “If mistakes were acrime, I’d be behind bars.” We knowthat no matter how important theissue, we can only go so far in over-coming our own limitations andthose of our environments. We makemistakes with our children, our par-ents, our spouses, and our finances.And, no matter how well intentionedwe are, and how careful we try tobe, we make mistakes in our work.

There are so many reasons formistakes. I once cared for a frail el-derly man soon after my father died.I was the attending physician, andwhen the house staff team argued todischarge the patient, as is naturalfor them to do, I backed them up, in-stead of insisting the patient and hisfamily be better prepared. He diedchaotically at home soon after. I real-ized, as I suffered through my ownself-criticism, that my perspectivehad been clouded by my father’sdeath just a few weeks prior. I felt itwas unfair that my father died de-spite being less frail than my patient.I had also been unable, in my owngrief, to confront the end-of-life plan-ning issues the patient’s situationposed. When the patient’s wifecalled me in distress to tell me howwrong I had been, I told her I hadmade a mistake, that I had not seenclearly, that it was due to what hadbeen going on in my own life, and Iapologized. She reached out from

her own grief to forgive me, showingthe deep humanity that is withinmost of our patients when we allowit to surface. I learned from her aboutmyself and about clinical care.

The work on mistakes by SGIMmembers, including articles in JGIMby Christensen et al. (1992) and Fis-cher et al. (2006), have helped meunderstand my experience in abroader context. Healing and learn-ing from mistakes, however, seemsto demand an experiential dimen-sion as well. I found this dimensionin a beautiful new movie by SGIMPast-President Tom Delbanco. Onanother level, Tom’s journey towardthis film is an example of the cre-ativity and learning that can comefrom paying focused attention towhat we and our patients experi-ence together. Through film, dis-comfort becomes shared experiencethat can help us improve. I askedhim to tell us what drew him to film,what it was like to make this one,and for general thoughts on use offilm by general internists. Tomwrote the following in response.

Peering Through a LensTom Delbanco, MD

It was as if a tornado came in andout... by the time the tornado left,there was a whole wake of ques-tions, conflicts, and emotional trau-mas and dramas...

—Son of man who died after a medical error

With our diverse patients, wide-ranging interests, and love for col-laboration, we generalists are ideally

PRESIDENT’S COLUMN

When Things Don’t Go Right: TurningMistakes into LearningLisa Rubenstein, MD

We make mistakes with our children,our parents, our spouses, and ourfinances. And, no matter how wellintentioned we are, and how carefulwe try to be, we make mistakes inour work.

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EDITOR IN CHIEFRobert Centor, MD rcentor@uab.edu

MANAGING EDITORChristina Slee, MPH cakuenneth@ucdavis.edu

EDITORIAL BOARDCaleb Alexander, MD, MS galexand@uchicago.eduStephanie Call, MD sacall@mail1.vcu.eduErin Egan, MD, JD erin.egan@uchsc.eduMolly Emott, MD Molly.Emott@vtmednet.orgDaniel Federman, MD daniel.federman@va.govDeepthiman Gowda, MD, MPH dg381@columbia.eduAdam Gordon, MD, MPH adam.gordon@va.govPaul Haidet, MD, MPH phaidet@bcm.tmc.eduMark Henderson, MD mark.henderson@ucdmc.ucdavis.eduFrancine Jetton, MA jettonf@sgim.orgCraig Keenan, MD craig.keenan@ucdmc.ucdavis.eduStefan Kertesz, MD, MSc skertesz@mail.dopm.uab.eduKarran Phillips, MD, MSc phillipsk@nida.nih.govHannah Shacter, BA hshacter@gmail.comMobin Shah, MD ShahM@uasomh.uab.edu

The SGIM Forum is a monthly publication of the Society of General Internal Medicine. The mission of The SGIM Forum is to inspire, inform and connect—both SGIM members and thoseinterested in general internal medicine (clinical care, medical education, research and health policy). Unless specifically noted,the views expressed in the Forum do not represent the officialposition of SGIM. Articles are selected or solicited based on topical interest, clarity of writing, and potential to engage thereadership. The Editorial staff welcomes suggestions from thereadership. Readers may contact the Managing Editor, Editor, orEditorial Board with comments, ideas, controversies or potential articles. This news magazine is published by Springer.The SGIM Forum template was created by Phuong Nguyen(ptnnguyen@gmail.com).

SGIM Forum

poised to make films. I first gave thecamera a try 20 years ago and havelearned that clinical care, teaching, andresearch can all profit from its ability tocapture insights, energy, and passion.

At the Picker Institutes here and inEurope, we called on patients and theirfamilies to serve as expert witnesses tocare. We published papers and a book,but these efforts left me feeling thatsomething was missing—they didn’tcapture the vividness of the patient ex-periences. It all came together for me inmy first foray into film. I watched, thenjoined, as my colleagues filmed patientsdescribing their recent hospital experi-ences in the film Through the Patient’sEyes. As examples:

I don’t think it should be totally up tothe patient to ask questions. I thinkthey should be led to ask questions.

—Musician after CABG surgery

Som Saha, MD, MPHOregon Health & Science University sahas@ohsu.edu

Mentoring relationships are likemarriages. They are the unitsthat form the foundation of any pro-ductive academic community. Thereare good mentoring relationships andbad ones. Bad relationships resultfrom poor matching, neglect, manip-ulation, or abuse of power. Good re-lationships are characterized bycommitment, responsiveness, andmutual appreciation. The best onesare enduring, but like marriages, theytake effort to sustain.

There are different ways to creatementoring relationships. Sometimesthey are arranged. This works best inmore traditional and paternalistic cul-tures, such as basic science, wherementor and mentee roles and re-sponsibilities are well defined. Thementee is taken into the mentor’s laband serves as part of the mentor’sscientific “family.” Eventually, the

forums for “speed dating” to expe-dite pairing. It may also be importantto look beyond one’s own institu-tion. While there is no substitute fora face-to-face relationship, Dr. Rightmay be out there somewhere, andin our modern culture, it is all rightto break with tradition if the best relationship is a long-distance one.

As opposed to marriage, in men-toring polygamy is the rule. Mentorsfill many needs: helping develop research agendas, providing careerguidance, assisting with navigationof rough academic waters, etc. Senior mentors can offer wisdom at 30,000 feet, while junior mentorscan often relate better to the challenges of being a fellow or new faculty member. It is relatively rareto find a single person to meet all mentoring needs.

Like good marriages, mentoringrelationships must be nurtured. Fewinstitutions adequately reward facultyfor mentoring. The reward is in see-ing mentees develop and succeed,

mentee becomes more senior, startsa lab, takes on mentees of his/herown, and continues the lineage.

Academic general internal medi-cine is a more modern, less tradi-tional culture. We usually want toblaze our own career paths ratherthan follow someone else. In thiscontext, arranged relationships tendnot to last. Finding the right mentorin GIM usually requires a process notunlike dating. When looking for amentor, find someone who seemslike a good fit, and approach him/her.Find a way to work together (e.g., aproject to collaborate on) to see if thementor is someone with whom youwant a long-term relationship. Doeshe/she seem genuinely interested inyou? Do you enjoy working withhim/her? Does he/she “get” you? Ifnot, move on.

When time for finding a mentoris of the essence, such as in fellow-ship, it is important for someone,usually the program director, toserve as matchmaker or to create

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HOW DO YOU DO THAT?

Finding a Mentor and Making it WorkRobert Centor, MD

These three takes on mentorship start to paint a picture for aspiring academic internists.Mentorship does not lend itself to easy description. Each junior faculty (and many mid-levelfaculty) should develop a personal strategy for growth. For some, that strategy will involveone particular wise mentor; others will need a team approach.

Many junior faculty members assume that their division chief will function as a mentor. I would advise some caution here. Division chiefs have a conflict of interest with juniorfaculty. They have work that needs doing—clinical sessions, committees to staff, etc.—andthus may assign tasks that do not really help the faculty member with career development.Division chiefs often actively coach junior members and perform some mentorshipfunctions. But they are less likely to give pure advice on some professional decisions.

I would also recommend that junior faculty develop peer-to-peer mentoring. This worksboth locally and nationally. As a junior faculty member I benefitted greatly fromconversations and exploration with local and national peers. Find colleagues at otherinstitutions, and compare notes. Part of growth comes from knowing the possibilities.Colleagues at other institutions can provide a different view of academic medicine thanthose at one’s own institution.

When I think back to my mentors, I now realize that I never thought of them in that way. I learned from them through philosophical discussions, practical discussions, and rolemodeling. I remember trying to emulate their strengths. Now I could name these mentors;then they were heroes or friends

The three descriptions presented here provide a good starting point. I personally believethat one should not worry greatly about mentorship; remember, many relationships areserendipitous. As one minor mentor reminded us often, using a quote from Louis Pasteur:“In the fields of observation chance favors only the prepared mind.” Both look formentorship, and also discover when it occurs.

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so be sure to share your successeswith your mentor—not just yourneeds. And like bad marriages, somementoring relationships must beabandoned. If a mentee is not follow-ing through with commitments, or ifa mentor is using the relationship forpersonal gain, get out. There may bepolitical or personal consequences toleaving a mentoring relationship, butin the end, it is rarely worth stayingwith an abusive mentor or neglectfulmentee. There are plenty of otherfish in the sea.

Judy Zerzan, MD, MPHUniversity of Colorado, DenverJudy.Zerzan@ucdenver.edu

“Managing up” is a common corpo-rate concept in the employee/super-visor dyad that also applies tomentoring relationships. The principleconcept is that the mentee owns therelationship by letting the mentorknow what he/she needs and com-municating in his/her mentor’s pre-ferred style. A motivated menteemanages the work of the relationshipby planning and setting the meetingagenda, asking questions, listeningactively, and requesting feedback.

Managing up gives you a frame-work that makes it easier to ask forwhat you need and overcome per-ceived barriers, such as not having aspecific direction.

Managing up also makes it easierfor mentors to help you by targetingadvice, critique, and support to spe-cific issues. It also makes the rela-tionship more rewarding for bothparties because your mentor canmake the most of his/her expertise.Lastly, managing up leads to a moreproductive relationship because thementor is able to look for specific op-portunities for you.

Managing up means you, as thementee, direct the relationship. Startwith a self assessment. Think aboutyour goals, motivations, strengths,weaknesses, pressures, and stres-sors. Identify your preferred work

come buried under the pressure ofclinical work, productivity demands,and educational responsibilities.

How do you find that specialmentor relationship? I advise facultymembers to look within their homeinstitution and their professional soci-eties. Start with your division chief,who can help you find your careerpassion and run interference for you.After discussing my hectic schedulewith my division chief that first year,he suggested that I run all requestsfor committee membership throughhim. Doing this ensured that all mywork either furthered my career ormet the needs of the division.

Consider different mentors forthe multiple aspects of your life. Arethere faculty members in your divi-sion, department, or institution whohave qualities that you admire? Finda reason to work with these individ-uals, and ask for their advice. Youmay acquire research, clinical, edu-cation, and “lifestyle” mentors overyour career. Set regular meetingswith these people, talk about goals,and set deadlines.

Attend your professional societymeetings, and get to know your fel-low members. Even a conversationwith the presenters of a workshopcan become an opportunity to find amentor. Ask colleagues for introduc-tions to Society members whosework you wish to emulate, and ex-change business cards. An electronicrelationship may soon ensue that willbe continue in person in the years tocome.

SGIM

style and your short- (three to sixmonths) and longer-term (two to fouryears) goals.

Once you identify a potentialmentor, you need to think about howyour mentor’s preferred work style,vision, goals, strengths, weaknesses,pressures, and stressors match up toyours. You should ask directly aboutyour mentor’s preferred communica-tion style. Does your mentor like toknow the detailed facts and figures,or is a broad overview with specificproblems better? Does your mentorlike to communicate by email, phone,or both? Is your mentor a “listener”or a “reader”?

Managing communication andmentoring meetings is key to a suc-cessful relationship. You can start byagreeing with your mentor on a regu-lar schedule feasible for time com-mitments and adequate to reachyour intended goals. Prepare for eachmeeting with a mentor by writing outan agenda, even if it’s just for you.Discuss relationship expectationsand review progress on a regularbasis (e.g. quarterly). Finally, youneed to make the effort to stay en-gaged and be appreciative.

Mentoring is a learning relation-ship that requires time and attentionto develop and results in successesand challenges. By managing up,both parties benefit from mentoringin terms of productivity, sharing ofideas, and satisfaction.

Elisha Brownfield, MDMedical University of South Carolinabrownfe@musc.edu

As a new faculty member in my firstacademic position, I rememberthrowing myself into every opportu-nity. As my calendar filled rapidlywith assorted committee work, clini-cal time, and projects, I realized that Iwould need to find direction in orderto carve out a true career. General in-ternists need mentorship today morethat ever. Career interests can be-

Lastly, managing up leads to a

more productive relationship

because the mentor is able to

look for specific opportunities

for you.

A61-year-old Caucasian man pre-sented with two weeks of pro-gressive swelling of his legs and feetand weight gain. He denied short-ness of breath.

His past medical history was no-table for hypertension, hyperlipi-demia, obesity, elevated fastingglucose, mildly elevated transami-nases, and psoriasis. A recentechocardiogram was normal. Medica-tions were amlodipine, lisinopril,atenolol, simvastatin, aspirin, andtopical treatments for psoriasis. Hedrinks four alcoholic beverages perday and does not smoke.

Examination showed a weight of263 lbs, up 18 lbs from three monthsearlier. Blood pressure was 153/71.Cardiac exam was normal, and hislungs were clear. No jugular venousdistension, ascites, or organomegalywas noted. 2+ peripheral edema waspresent bilaterally. He had psoriaticplaques on his elbows.

This patient presents with newlower-extremity edema. Edema is afrequent presenting complaint andphysical finding in the primary caresetting and has a variety of etiologies.

Edema may be caused by eitherretention of sodium and water or adisruption of hydrostatic/oncoticpressures in peripheral capillaries.Retention of sodium and water maybe due to renal dysfunction or med-ication effects (e.g. thiazolidine-diones), a compensatory responsefrom the kidneys to poor cardiacoutput (e.g. CHF), or to decreasedsystemic vascular resistance (e.g.cirrhosis). At the capillary level, anincrease in hydrostatic pressure(e.g. venous insufficiency or throm-bosis), a decrease in oncotic pres-sure (e.g. hypoalbuminemia), or anincrease in capillary permeability(e.g. sepsis) may lead to an accumu-lation of excess interstitial fluid.

In this case, I’m concerned aboutthe acuity of the presentation and

The kidneys normally excreteless than 150 mg of protein a day;urine dipstick testing can usually de-tect urinary protein that exceeds300 mg/day. In cases of persistentproteinuria, it is important to quan-tify the amount of protein loss witha spot urinary protein to creatinine(UPC) ratio. The UPC ratio correlatesvery well with 24-hour urine proteinmeasurement1 and is less burden-some for patients.

Microscopic hematuria is usuallydefined as the presence of two ormore RBCs per high powered field. Ifpersistent, both non-glomerular andglomerular causes must be consid-ered. Abnormalities within the kidney(e.g. cancer, polycystic disease, papil-lary necrosis), ureters (e.g. stones,urothelial malignancy), bladder (infec-tion, cancer), prostate, or urethracause non-glomerular hematuria. Inthis case, dysmorphic red cells andthe concomitant presence of proteinsuggest a glomerular origin of hishematuria.

The spot UPC ratio was 3. A CTscan of the abdomen and pelvis wasnormal.

Once again, the proteinuria,hematuria, and dysmorphic RBCs allsuggest an active glomerularprocess. I would obtain a renal con-sultation and consider a renal biopsy.

In general, glomerular diseasespresent along a spectrum of two clin-ical patterns: the nephrotic syndromeand the nephritic syndrome.Nephrotic syndrome is characterizedby > 3 g of proteinuria per day, hy-poalbuminemia, edema, and hyper-lipidemia. Nephritic syndrome ischaracterized by hypertension, hema-turia, and variable degrees of renal in-sufficiency. However, there may beconsiderable overlap between thesetwo patterns.

The patient’s edema, hypoalbu-minemia, hypercholesterolemia, andproteinuria suggest nephrosis; the

the dramatic weight gain, whichmake more chronic conditions likevenous stasis unlikely.

A normal cardiac exam and recentechocardiogram make cardiac dis-ease less likely. The patient reportssignificant alcohol use and elevatedtransaminases, raising concern for cir-rhosis. I would order a serum albuminand other indices of liver function, as well as a serum creatinine and urinalysis to assess for proteinuria.

Laboratory studies showed: crea-tinine, 0.9 mg/dL; albumin, 2.3 g/dL(baseline of 3.8 g/dL); normal liverpanel; BNP, 111 pg/mL [5-100]; CBCnormal except platelets 111 K; INR,1.2; and cholesterol, 228 mg/dL. Urinalysis revealed 2+ protein, 3+ blood, 1 wbc/hpf, and 61 rbc/hpf;no casts were noted.

He was prescribed 40 mg offurosemide daily, and his edema resolved.

I’m impressed by the abrupt de-cline in his serum albumin. I wouldassume that this low serum albuminhas contributed to his edema. Hy-poalbuminemia may result from nu-tritional factors (e.g. poor intake ormalabsorption), decreased produc-tion (e.g. cirrhosis), or loss of albuminin the urine. In this case, the pres-ence of marked proteinuria suggestsurinary losses as the culprit.

The presence of microscopichematuria also merits further evalua-tion. The first step would be to re-peat the urinalysis and personallyexamine the urinary sediment underlight microscopy. False positive dip-stick protein results can occur, withhighly concentrated or very alkalineurine or with gross hematuria. Simi-larly, transient microscopic hematuriamay occur from physical exertion,mild trauma, or sexual intercourse.

A repeat urinalysis showed 1+protein, 3+ blood, 2 wbc/hpf, and 46rbc/hpf. Dysmorphic RBCs were alsonoted, without RBC casts.

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OUTPATIENT MORNING REPORT

A 61-year-old Man with Lower Extremity Edema, Proteinuria, andMicroscopic Hematuria Amy Schwartz, MD (presenter), and Juliette Spelman, MD (discussant, in italic)

Dr. Schwartz is Assistant Professor, Yale University School of Medicine and VA Connecticut Healthcare System. Dr.Spelman is Assistant Professor at Yale-New Haven Hospital.

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presence of hypertension, hematuria,and dysmorphic RBCs indicate a con-comitant nephritic component.

Common etiologies for nephroticsyndrome include: diabetic glomeru-losclerosis, minimal change disease(often related to NSAIDs or lympho-proliferative disease), membranousnephropathy (often related to hepati-tis B infection or solid tumor malig-nancies), focal segmentalglomerulosclerosis, amyloidosis, orHIV-associated nephropathy.

Common etiologies of nephriticsyndrome include membranoprolifer-ative glomerulonephritis (often re-lated to autoimmune disorders,hepatitis C infection, or bacterial en-docarditis), post-streptococcal nephri-tis, lupus nephritis, vasculitis, or IgAnephropathy.

To initiate the workup, I wouldsend Hepatitis B and C serologies, HIVtest, SPEP and UPEP, ANA, ANCA,and serum complement levels.

Hepatitis B and C serologies, HIV,ANCA, and ANA were all negative.SPEP, UPEP, C3, and C4 levels werenormal. A renal biopsy performedone month later showed findingsconsistent with IgA nephropathy.

IgA nephropathy, an immunecomplex-mediated glomerulonephri-tis, is the most common primaryglomeruolonephritis in the world. Itis defined immunohistochemicallyby the presence of glomerular IgAdeposits and a variety of histopatho-logical features, most commonly ex-pansion of the mesangium anddeposition of other immunoglobu-lins. The cause of IgA nephropathyis unknown.

Aberrant glomerular IgA deposi-tion can occur as an isolated entity(primary IgA nephropathy) or as partof a systemic illness (Henoch-Shon-lein purpura, HSP). Our patient didnot have the systemic findings, suchas purpura, arthralgias, or abdominalpain, that typify HSP. Secondarycauses of IgA nephropathy includeautoimmune disease, psoriasis, andpossibly alcoholic liver disease,which may explain why our patientwas affected.

IgA nephropathy has a 6:1 malepredominance in the United States. Itcan occur at any age but typically af-fects patients in their 20s or 30s.Younger patients often present withflank pain and gross hematuria (e.g.“tea-colored urine”) after an upperrespiratory illness. Older patientstend to present with incidental find-ings on urinalysis.

The clinical course of IgAnephropathy is variable, with 15% to40% of patients progressing to endstage renal disease. Treatment of IgAnephropathy is usually reserved forpatients with persistent proteinuriaand hypertension who are at highrisk for disease progression.

While studies are limited, ACE in-hibitors are generally accepted asfirst-line therapy because they effec-tively lower blood pressure and limitproteinuria. Angiotensin receptorblockers may be added as adjunctivetherapy. Corticosteroids are reservedfor patients with significant proteinwasting or progressive renal dysfunc-tion. Based on their anti-inflammatoryproperties, fish oil, or N-3 polyunsatu-rated fatty acids, has been studied

with varying results. Finally, rapidlyprogressive disease may merit treat-ment with cytotoxic drugs.

The patient was already on anACE inhibitor at the time of presenta-tion. Due to the degree of his pro-teinuria, he was also started onsystemic corticosteroids. His renalfunction has remained normal.

Key Points• Significant dipstick proteinuria

should be quantified with aurinary protein-to-creatinine ratio.

• Persistent microscopic hematuriacan be classified as eitherglomerular or nonglomerular inorigin. The presence ofdysmorphic cells and proteinstrongly suggests the latter.

• IgA nephropathy is the mostcommon primaryglomerulonephritis worldwide. Itis often asymptomatic in olderpatients and may present withincidental urinalysis findings.

• Treatment of IgA nephropathydepends on disease severity andthe likelihood of diseaseprogression. Typically, it involvestight blood pressure control, ACEinhibitors, corticosteroids, and/orcytotoxic agents.

References1. Price CP, Newall RG, Boyd JC.

Use of protein:creatinine ratiomeasurements on random urinesamples for prediction ofsignificant proteinuria: asystematic review. Clin Chem2005;51:1577-86.

SGIM

ESSAY: THE VARIOUS HANDOFFScontinued from page 2

code blues, a lot of it is quite pre-dictable. If you give a patient Lasix, itwill make her pee and become hy-pokalemic, which will make the resi-dent give IV potassium, which willburn, requiring replacement with pohorsepills, which will make the pa-tient vomit. You can choose to seethat patient before or after the unfor-tunate series of events. But you sim-ply can never create a to-do list orset of goals with children or try to

needs to be washed.” “Mom, didyou check on Baby while I was atschool?” “Mom, Baby needs sun-screen.” “Wow, you are such a goodmommy,” I say, concomitantly think-ing to myself, “better than I am,” asI stare at my scrubs walking them-selves to the laundry. “Yes, well Iwant to be a mommy, a princess,and a doctor when I grow up—justlike you Mom,” my daughter replies.

multitask, such as reading an articlewhile they play. And after seven daysand more than 80 hours of immer-sion in patient care, the transition tonebulous pretend world and whimsi-cal toddler and pre-school moodswings is—I’m convinced—the mostchallenging thing I do. And one I feelI don’t do well at all.

My eldest daughter spends a re-markable amount of time motheringher baby doll. “Mom, Baby’s dress continued on page 13

Kim Davis, MD Medical University of South Carolina Charleston, SC

Would you please describe your innovation?Faced with consolidation of two clinics, we needed toimprove efficiency of patient care within a universityteaching and faculty practice while enhancing quality ofcare and patient satisfaction. This was done by:

1. Enhancing practice environment with four roompods and visit process changes;

2. Making nurse case managers accountable topatients, physicians/residents, and nursing;

3. Placing a computer and printer in every room foraccessing the EMR;

4. Creating a matrix management structure forphysicians and hospital staff;

5. Developing strategies to manage excessivetelephone calls;

6. Improving access to care;7. Standardizing physician schedule templates;8. Reconciling outpatient medication at every visit; and9. Improving payer mix.

Pod Structure and Visit Process. Architectural renova-tions, ostensibly made to increase the number of exami-nation rooms on the floor from 29 to 33, resulted in agroup of four-room clusters called PODs, each with anassigned nurse and patient-care technician located at thecenter. The POD environment improved professional ac-countability between nurses and physicians, helping en-hance patient flow. Nurses perform pre-visit chart reviewand preparation (e.g. mammogram request is printedprior to patient visit) and address care coordination. Pro-tocols for medication refills and standing orders for pre-ventive care and screening (e.g. influenza immunization,mammogram forms) were implemented. The RN seesthe patient prior to the physician and reviews the med-ication list with the patient. All needed medication refillsare printed and left for the physician for signature. ThisPOD structure and case manager/nurse accountabilityensures that all of the data needed to efficiently care forthe patient are available to the physician at the point ofcare. The physician is not tasked with spending timesearching for information—support staff are responsiblefor gathering or cueing up information.

Case Management. To build close, accountable work-ing relationships among 24 faculty, 98 resident physi-cians, two PAs, and 23 clinical staff and their respectivepatients, teams were assembled around 10 nurse casemanagers. These case managers served as the primarycontact for both the physician and the patient. Teamsconsisted of three to four attending physicians/nurses

and seven to eight residents/nurse case manager, andeach patient was introduced to his/her case manager atthe initial visit. Nurses were empowered to channel pa-tients into University Internal Medicine (UIM) clinic usingfreeze-thaw schedules, Rapid Access Clinic (RAC) ap-pointments, or residents rotating on UIM acute care ro-tation. In February 2009, renovations were completedfor a new centralized precepting area away from examrooms and patient traffic to protect confidentiality andenhance the teaching environment.

Use of Information Technology. The clinic mergerwas an opportunity to expand electronic resources andenhance the use of the electronic medical record, Prac-tice Partner ® (PP). Each of the 33 examination roomswas equipped with a computer workstation and printer,facilitating the use of PP features such as prescriptionprinting, drug interaction checking, and patient medica-tion lists. All faculty and residents are expected to up-date and print all medications on PP and print anaccurate, updated medication list for patients at the endof each visit. All PCs are linked to Medical University ofSouth Carolina (MUSC) library knowledge resourcessuch as Up-To-Date™, PubMed, e-journals, Micromedex,and others. The commitment to information technologyin the UIM has been substantial: 89 desk-top comput-ers, two computers on wheels, and 53 printers in theUIM clinic space support faculty, residents, and clinicalstaff, including two PharmDs and a certified diabetic ed-ucator, in 33 exam rooms and five conference areas.

Management Structure. The “triad” of leaders fromeach major area of the clinic—physician clinic director,nursing director, and scheduling/registration liaison—meet on a monthly basis. The group reviews opera-tional and patient flow patterns and communicatesopportunities for improvement. The meeting provides aforum for creative ideas, dissemination of changes, andcommunication among clinic faculty and staff. Eachleader is responsible for communicating back to his/herconstituent group.

Telephone Volume. Managing telephone call volumeremains a challenge—more than 1,200 calls are directedto UIM scheduling and nursing each week. To manageand direct this volume of calls, a patient Message Tem-plate with drop-down menus was developed to collectinitial call data into PP and route the message appropri-ately. All physicians are encouraged to draw labs prior toappointments so that the results can be reviewed at thetime of the visit. UIM purchased ISTAT meters to adjustwarfarin dosage before patient leave the clinic. Afteralerting area pharmacies, the UIM-recorded phone mes-sage was changed to ask patients to request refillsfrom their pharmacies, and the pharmacies were askedto fax the refill requests. In February 2009, e-prescribingwill begin to replace the fax refill mechanism.

8

PRACTICE INNOVATIONS

Innovations at MUSC and Grady Memorial HospitalKim Davis, MD, and Jada Bussey-Jones, MD, in conversation with Christine A. Sinsky, MD

Improved Access to Care. We established a same-day Rapid Access Center (RAC). UIM guarantees thatexisting patients or employees will be seen by a fac-ulty member the same day if they call before 4 pm.Faculty also began using the IDX feature called“freeze-thaw,” which opens a pre-determined numberof appointments 48 hours before the session opens.These appointments are only accessible to PODnurses. POD nurses are empowered to add patientsto schedules or route patients to the RAC as they seeappropriate.

Standard Schedule Templates. Faculty templateswere standardized to schedule new patient visits for 40minutes and return visits for 20 minutes. The facultyand resident practice start times were varied so that pa-tients did not arrive at registration at the same time.Clinic cancellations must be requested six weeks in ad-vance to minimize rescheduling of patients.

Medication Reconciliation. Medication reconciliationis a part of each visit at UIM. The medication list isprinted out from the electronic record and reviewedwith the patient via the nursing staff; those medicationsneeding refills are highlighted and left for physicians.

Improve Payer Mix. We used the Rapid AccessClinic as an opportunity to build our Faculty and Resi-dent Practice with new patients that are commerciallyinsured.

What stimulated your organization to make these changes?The Department of Medicine and University Hospitalmandated that the two large resident and faculty Gen-eral Internal Medicine clinics consolidate on a singlefloor in the ambulatory care tower. Although the UIMclinic sees more patients per day than any clinic atMUSC, it was allocated less space, fewer support staffoffices, and fewer examination rooms (a reduction from40 to 29 rooms) than the two clinics historically. Addi-tionally, faculty compensation was tied to productivityincentives.

What was critical to your success?Teamwork among the nursing staff, administration,and physicians led UIM to its success. All planning ac-tivities were guided by an all-day strategic planningmeeting, held off-campus by two facilitators. Both clin-ics were closed, and all staff, faculty, and schedulerswere included. Seventy-five participating faculty andstaff were carefully assigned to tables to assure a mixof faculty, nursing, and administrative staff and leader-ship at each table. Staff and faculty shared successesand frustrations. For example, non-standard appoint-ment templates among faculty caused schedulingproblems; MD clinic cancellations at short notice werecausing large amount of rework for schedulers; nurseswanted and needed more autonomy and requestedstanding orders; phone call volume was excessive es-pecially for medication refills; and acute care capacitywas very limited, putting schedulers and nurses in theposition of turning away patients.

What challenges did you face and how did youovercome them?Importantly, the faculty and staff of the two clinics re-flected two medical cultures. The University DiagnosticCenter (UDC) was a traditional academic Internal Medi-cine diagnostic clinic serving the insured Charlestonpopulation for more than 30 years. McClennan-Bankswas a County Hospital-based clinic developed to serveMedicaid managed care patients. Clinical and adminis-trative staff, many of whom had never met, wouldwork closely together in the merged clinic. Physiciansfrom two different age generations would come to-gether and develop a new set of goals for University In-ternal Medicine leaving behind the “this is the waythings have always been done” mentality. In addition,there was a “new productivity pressure” placed on thefaculty that had not existed in the past, which broughtthe group together. This emphasis on through-putpulled the group together.

Do you have any data demonstrating the effectiveness of your innovation?Press-Ganey patient satisfaction measures have fluctu-ated, but we have been quite pleased with our overallsatisfaction scores. The impact of our innovations is re-flected by several scores that are at least one standarddeviation above our peer group: ease of scheduling,phone courtesy, helpfulness, wait time in exam room,convenience of office hours, and information providedabout medications. In the Press-Ganey report for thesecond quarter of FY 09, UIM ranked in the 95%ile forGeneral Internal Medicine comparison practices.

Aggregated physician productivity, patient visits, andgross collections have all risen since the clinics mergedin the fourth quarter of FY 05. Figure 1 shows annualUIM faculty RVU growth exclusively for the outpatientsetting. Almost all UIM faculty now exceed the MGMA75%ile RVU productivity.

Figure 1

Figure 2 shows relatively steady and sustainedgrowth in clinic patient volume, despite fluctuation in al-located faculty physician and resident clinical time. Al-though faculty would readily admit they are busier thanin the past, they do not feel that the current visit vol-ume is unmanageable.

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continued on page 11

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PRESIDENT’S COLUMNcontinued from page 3

My major concern, regardless ofwhat it is, is that I need information.That’s my basic food.

—Young man with AIDS, whenAZT was the only drug

It’s very, very important to listen towhat the patient is saying. Patientsmay not have the foggiest idea whatthey’re talking about, but it’s theirproblem, their life, their concern,and you’ve got to listen to the poorbastards!

—Retired bank president withcardiac disease

Next came Clinical Crossroads.Focusing on dilemmas patients andtheir doctors face, each JAMA publi-cation records a live grand rounds.No matter how accomplished ourexpert discussant, the highpoint isalmost always our short film pre-senting the patient’s perspective.We worried initially about how pa-tients would do on camera, but ourfears proved unfounded. Among155 patients, almost all have hadsomething unexpected and eloquentto say. Just this February:

I broke out in a cold sweat. I be-came incredibly hot, then incrediblycold...and it was like looking at my-self, watching this happen, and feel-ing completely helpless...

—Office manager with a pulmonary embolism

Five years ago, a close friend andgreat violinist experienced a medicalerror that led to his death. I filmedhim, and then other patients andfamilies in the midst of life-alteringtrauma following a medical error.This trip into the unknown provedboth more exhilarating and frighten-ing than any I had experienced dur-ing my years as a doctor.

As it evolved, we interviewed 51individuals who offered not onlystriking words and pictures but alsostructure. Their experiences fell intodiscrete categories, obviating anyneed for confidence intervals or p

values. We learned that medicalerror invariably assaults the emo-tions, places enormous demands oncommunication and trust, invokesthe currently hot topic of apology,and poses the question: How can allconcerned approach closure?

In addition, we gained three in-sights virtually absent from the liter-ature. First, we often shy away fromthose we harm, isolating patientsand families just when they need usmost. Second, I know how guiltywe feel after making mistakes, butboth patients and family membersmay agonize over similar or evengreater guilt (“If only I had...”). Third, patients and their familiesmay fear further harm from doctorsand institutions. Many are terrifiedof speaking up; fear of retributionwas the main reason for refusingour camera.

Showing the first rough cut ofWhen Things Go Wrong: Voices ofPatients and Families to doctors at aconference on medical error wasnot easy. The film is tough, bad-tast-ing medicine. Why rub it in, whendoctors often feel similar emotions?Yet that day, the power of filmstruck deep. Signed by an internist Iknow and respect, an evaluationform vilified me for attacking doc-tors and for showing starkly only thepatient and family perspective—justone side of the coin. But shortlyafter handing it in, the internistrushed up to me and exclaimed,“I’ve just been through denial,anger, and depression, and have Ilearned a lot! Tear up my form. Thisfilm has changed the way I think...”

Some suggestions for creatingfilm:

• Remember the rule of thegeneralist: We can’t doeverything well. We know aboutmedicine. Film producers,“shooters,” and editors knowabout film. As we do so often inour work, collaborate!

• Roll the camera, and don’t talktoo much. Ask open-ended

questions. Let silence speak.Remember that the best “stuff”comes just when everyonethinks the interview is over.

• Stay away from actors andnarrators! No one can play thepart as well as the patient, familymember, or clinician.

• Don’t try to make film didactic,but aim rather to moveaudiences. Emotions breedpowerful response, interaction,and debate.

Recall the dismal facts about ourdidactic lectures: A week later, stag-geringly few who came to listen re-member points we made or eventhe topic itself. But I find that filmcan turn people on to what excitesme, at times persuading them topursue the topic further well aftermy words fade.

Those I have filmed have mademe a better doctor. Except whenequipment fails, I never teach smallor large audiences without showingsome film. (And if you don’t makeyour own, you can likely find rele-vant footage to make your point.)And finally, I believe that what ourcameras have captured over theyears has proven vital to bona fideresearch.

But we shouldn’t be surprised bythe power of film for our profession.It both invites people to speak...andhelps us listen.

Special thanks to Dr. Delbancofor his contribution to the SGIMForum. He can be reached at tdel-banc@bidmc.harvard.edu, and theeducational DVD When Things GoWrong is available fromhttp://www.rmf.harvard.edu. We areworking on getting SGIM membersa major discount when ordering theeducational DVD that contains thefilm and a lot more. To provide com-ments or feedback about this col-umn, please contact LisaRubenstein at Rubenstein.Lisa@g-mail.com.

SGIM

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Gross collections for UIM increased 15% in FY06,33% in FY07, and 8% in FY08, rising from $900,000 inFY05 to more than $1.5 million in FY08. This growth,however, reflects not only volume and productivity in-creases but also changes in payer mix.

We are striving at UIM to achieve a model of carefor our patients, residents, and students that empha-sizes safe, timely, patient-centered, effective, efficient,and equitable care. In our most recent round of renova-tions, we have constructed a resident precepting roomthat creates a more conducive teaching/learning envi-ronment and improves patient confidentiality. It is withpride that we note that General Internal Medicine hasbeen chosen Division of the Year by vote of the InternalMedicine residents for the last five years in a row.

In the past, financial performance and visit volumeswere the only accurate data available on clinic perfor-mance, but UIM has begun tracking and reporting nurseand physician process of care data. For example, JCAHO-required annual screening by nurses rose from 35% inFY07 to more than 90% in FY08. We have begun using“green sheets” as a reminder for nurses to vaccinate pa-tients. Nurses check a box on this “green sheet” to com-municate immunization status with one of three choices:accepted today, received elsewhere, and refused. Morethan 95% of all UIM patients were screened in the pastyear; in the last three months of CY08, UIM nurses ad-ministered more than 2,400 immunizations.

Any closing thoughts?Our success is reflected by the following: The facultypractice is close to full, patient satisfaction has im-proved, physicians and staff are happy, and we havehad no clinical staff turnover in two years. We feel thatUIM is well prepared to become an outstanding Patient-Centered Medical Home.

Jada Bussey-Jones, MDGrady Memorial HospitalAtlanta, GA

In a nutshell what was your innovation?We developed a plan to merge the Urgent Care Centerwith the Medical Clinic to become the Primary Care

Center (PCC) of Grady Memorial Hospital. With this inno-vation, two distinct practices became one and maintainedopen and advanced access for same-day and urgent visitsas well as increased emphasis on and ability to establishprimary care. Specifically, the planning and eventual merg-ing of these practices had several outcomes including: de-creased patient barriers and improved access to primarycare, provision of subacute care in patients’ primary caresetting with the medical record available, improved re-source utilization (decreased non-billable visits), provisionof new services (phone-in prescription refill, urgent ap-pointment scheduling, phone messaging, and triage sys-tem), and improved clinic efficiency.

What problem or opportunity stimulated your organization to make these changes?In 2005, our internal medicine physicians staffed boththe “Medical Clinic” and the “Urgent Care Center”(UCC) in separate areas. The UCC provided episodiccare that required patients to walk in and wait to receiveall services. Simultaneously, the Medical Clinic (continu-ity clinic) had limited telephone and acute care access.Early in 2005, we conducted a study of the patients pre-senting to the UCC for treatment. The results demon-strated that a significant majority (72%) of patients hadno primary care physician. Additionally, nearly 20% ofthe visits were not billable (e.g. writing refills and refer-rals). Before the change, the UCC functioned much likemany emergency departments—patients were evalu-ated without medical records, had to walk in and waithours to be seen, and had limited access to primarycare. (A referral was required to the medical clinic eventhough the providers were the same.) At the same time,a long-term Medical Clinic patient wanting to be evalu-ated for an attack of gout would be required to utilizethe walk-in-and-wait model in the UCC. We sought toaddress all of these issues with our innovation.

What two or three elements were critical to your success?The development of the primary care call center and in-tegration with the medical records computer requestsystem were central components of our innovation.While call volumes are high and many issues remain, pa-tients now have unprecedented telephone access to thePCC. This includes access to scheduling services, phar-macy services and refills, interpreting services, financialcounseling, social services, customer service/advocates,advice nurses, and nurse/ physician messaging.

Organizational buy-in and engagement were alsocritical, as wide spread changes impacted the daily re-sponsibilities of hundreds of physicians and staff. Wehad multiple sessions over the year designed to gatherinput, build teamwork, and provide information. Staffand physician feedback as well as continued objective

PRACTICE INNOVATIONScontinued from page 9

continued on page 14

Figure 2

seems to be no way for him to ad-dress it with the parties involved.

At my hospital, we have a system(phone number) for patients and theirfamilies to raise without fear anyquestions or concerns at anytimeabout any aspect of their care whilethey are in the hospital. We stronglybelieve that patients should notworry that they may suffer retaliationfor raising concerns about their inpa-tient care. Patients are encouragedto speak directly with the hospitalistcaring for them. Hospitalists are en-couraged to take time to communi-cate with their patients. The “serviceexcellence” staff collects the infor-mation from the patient, which usu-ally begins with feedback about thehospitalist caring for the patient. If itcan’t be resolved at that level, theneither the hospitalist arranges for acolleague to take over the patient’scare per the patient’s preference orhave me handle it. It’s rare thatthings ever get to that, but I will re-assign the patient to another hospi-talist if it’s requested or in my bestjudgment. We strive to resolve all pa-tient complaints on the same day.The system definitely works becausepatients and their families use itwhenever they feel they need to doso. We want to address all patientconcerns while the patient is still inthe hospital and not after discharge.

Yes, this patient has the right toask for another hospitalist to carefor him. Most hospitalists wouldalso agree that the “fired” hospital-ist needs feedback so that behavioris modified or needed changesmade. In a very small program, thepatient may not have a choice, butthe same could be said for choice ofinternist in a very small or rural com-munity. When the patient fires theinternist, most of the time the in-ternist never receives any feedback.The patient just stops coming toclinic, and nobody asks why.

James D. Franko, MD, and Bruce E Johnson, MDVirginia Tech CarillonThe only simple answer, analogousto “firing” an outpatient doctor, is

medicine group. A short review ofthe case is done, and concerns areelicited. Initial attempts are made atservice recovery and reconciliation ifpossible. If a change is indicated, aleader discusses the change with thecurrent team and a receiving team.Choice of receiving team is informedby the specifics of the concern. Wecurrently have seven hospitalist-ledgeneral internal medicine services—six teaching and one non-teaching—so there is ample availability ofalternate caregivers.

All cases are retrospectively peerreviewed. In most cases, there are noovert medical issues. There is gener-ally much to be learned in the area ofcommunication with patients andfamilies. Specific concerns that ariseare the time spent with providers, at-tention to family as well as patientneeds, cultural competence, listeningskills, and non-verbal communication.

Patience Agborbesong, MDWake Forest UniversityI suppose some hospitalist programshave an implicit conflict with patientpreferences, but I think those are inthe minority. Hospitalists are used tobeing measured, and patient satisfac-tion scores and feedback are thingswe have embraced since the begin-ning of our field. Patient satisfaction,in particular, was important to us be-cause of legitimate concerns raisedearly on about taking care of patientswhom we would not follow in theoutpatient setting. Most of those con-cerns proved to be unfounded partlybecause we were sensitive to them.Patient satisfaction remains so impor-tant to us that quite a lot of us havesome percentage of our pay tied to it.

I don’t have enough of a context inthe case presented to make specificcomments, but something is striking.It appears the hospitalist is not awarethat this patient has a grievance anddoesn’t want him/her involved in hiscare. That’s unacceptable. He/sheneeds that feedback even if the pa-tient switches doctors. It’s also sadthat the patient has to write to a com-plete stranger to express his frustra-tion with the situation because there

12

EDITORIAL: CAN I FIRE MY HOSPITALIST?continued from page 1

yes, if the patient can name a re-placement outside the hospitalistgroup and that doctor readily ac-cepts. Otherwise, the challenge isto search for a cause of discontentand address that cause. (The ethi-cally correct action in the meantimeis for the hospitalist to continue pro-viding medical care to the patient.)

The following suggestions mayhelp the medical team understand theroot cause of the patient complaint:

• The hospitalist should ask for,and document, the specificreason(s) why the patient wishesto change doctors.

• The hospitalist should seek aremediable issue—hopefully littlemore than a misunderstandingregarding diagnostic workup ortreatment plan. The patient whomakes unreasonable demandsrequires greater patience.

• Issues related to caring,attention, incorrect assumptions(“saving the IPO/HMO money”)are equally important but aremuch more difficult to resolve.

• Eliciting the support of a thirdparty, such as a nursingsupervisor, may help identifyunknown information leading toresolution.

Changing doctors within thesame hospitalist group is fraughtwith difficulties. Scheduling issuescannot guarantee the patient will re-tain the new hospitalist through theremainder of the hospitalization orthat the “new” doctor will be avail-able at subsequent admissions. Theafflicted doctor may unfairly gain thereputation as a “slacker,” and thepatient may feel empowered to“fire” other doctors.

These issues are quite importantto the hospitalist group, especially ifthat group provides the only hospitalinpatient medicine admitting services.Patient accusations inevitably affectthe entire group through disruption ofpatient load/numbers, damaged repu-tation, and even poor medical care.Frequent occurrences can lead to re-crimination and enmity within the

13

hospitalist group. Consequently, thehospitalist doctor, or the group/sec-tion head, should make every effortto resolve the patient concern with-out changing the hospitalist doctor.

If no resolution is forthcoming, itshould be made clear to the patientthat he/she has responsibility to assistin contacting an acceptable receivingdoctor. Nonetheless, there seem tobe only two ethical solutions: reassignthe patient to another doctor, even inthe same hospitalist group, or arrangetransfer to another hospital.

Ben Taylor, MD University of Alabama at BirminghamI think of this post as having an easy answer, while raising tougher questions.

First, “Can I fire my hospitalist?”.The answer is yes. It may be as easyas changing to someone else on ser-vice or working on that same floor.Smaller programs may have to be alittle more creative, but usually eventhe smallest groups have some capa-bility for alternative arrangements ifthings aren’t working.

Now, to the tougher and perhapsmore salient question: “What is it be-tween this hospitalist and this patientthat just isn’t working?”

Not to get too Dr. Phil-ish, but thefirst question that comes to mind is“What else is going on?”. If thiswere a case being presented to uson morning rounds, I think most ofus would be waiting for the “punchline” or the real reason we’re eventalking about this in the first place.The crucial framing or contextseems to be missing here. I justcan’t escape the sense that there issomething else going on. Am I cyni-cal in thinking that this patient loveshis cardiologist and internist becausethey are the “same” people, be it inlanguage, belief, or skin color? Ihope I’m wrong, but unfortunately,that still comes to mind.

Maybe it is this hospitalist. Werecognize and have mechanisms toaddress the “impaired physician” butno great way of identifying and deal-ing with the plain-old “major leaguejerk”—a slightly altered version ofthe descriptive moniker so eloquentlyused by our former president. Identi-

fying such physicians is crucial formany reasons since communication(or lack thereof) is inextricably linkedwith patient care experience andoften serves as a major contributor indecisions to pursue malpractice litiga-tion. “Nitro drips and a few tests”sound like appropriate medical carefor the conditions described, so whydoes this patient feel that this hospi-talist treated him so inappropriately?

Maybe it is this patient. I’ve beenhired for being “the best doctor inthe world” and “the only doctor whowould listen.” I’ve also been fired forbeing “the worst doctor in theworld” and “just like everyone else”—often by the same patient. The“difficult patient” is a well-recog-nized and nuanced concept in medi-cine and medical education. Thus,we are often better prepared to dealwith the “difficult patient” than weare the “difficult colleague.”

So back to our original question:Can a patient fire the hospitalist?Sure, but fixing the problem requirestruly understanding why one wantsto do so in the first place. That is thequestion that must be answered. SGIM

ESSAY: THE VARIOUS HANDOFFScontinued from page 7

“Yes, well, you’ll likely feel that youdo none of them very well then.” Idon’t actually say that, and I alsodon’t comment on the state of myprincess-hood.

This tension between motherhoodand a career as a physician is con-stant. Why don’t they call it the Prac-tice of Motherhood just like thePractice of Medicine? I’ve often dis-cussed with colleagues a sharedsense of anxiety upon returning towork after a couple of weeks off. Butit’s not a hot topic to discuss feeling“out of practice” with motherhood.Who wants to admit that, even tothemselves? It’s one thing to be finan-cially employed part-time, but no one’sa part-time mother. When I’m not atwork, of course I’m in Mom Mode,right? I have all the patience in theworld when one daughter can’t get ridof her wedgie and falls on the floor ina heap of sobbing exasperation orwhen the other screams “No,

the constant learning, and the closerelationships to families are what Ihave thrived upon since residency.And of course, the hours allow me towork “part-time” without call andhave weeks at a time as Mom. Butthere’s the catch: For both practices, Imust and want to be fully present.Can you really do either part-time?

New literature comes out con-stantly, standards of care change, andthe differential diagnosis is a practicedskill. But my children change daily andthus need a parent practiced in flexi-bly responding to their emotionalneeds. But I’ll admit that it takes me agood two days, sometimes more, tofeel seasoned in motherhood againafter a week at the hospital. And forthe next four days I’ll love and blos-som and relish in the practice of it andwonder why I ever leave it. But thenSunday rolls around...and the Handoffcall comes in...and it’s anything but aseamless internal transition. SGIM

Mahself” and demands to climb intoher own car seat when it’s raining. Ilove playing princess, especially whenthe basic rule is “No, Mommy, youmake the dolls talk.” My mind neverwanders to what’s happening with myrecent patients or what recent litera-ture shows about their disease. Andcome 9 pm when everyone is finallyasleep and the kitchen is cleanenough to at least prevent ants, ofcourse I’m ready to sit down and readthe New England Journal of Medicine.Just because I work part-time doesn’tmean I can read part-time. “The Bach-elor” or “American Idol”? Never.

I don’t think there are any reviewarticles or research papers on how todo this physician/mother mental hand-off, and certainly there are no out-comes data. And as for a white paper,I’m struggling to write one for myself.I enjoy working, and I love my job asa hospitalist—the type of patient care,the interaction with subspecialists,

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Physician-ResearcherCenter for Healthcare

Knowledge Management East Orange, New Jersey

U.S. Department of Veterans AffairsResearch and Development Program atVA New Jersey Health Care System,East Orange, New Jersey, is recruitingfor a physician-researcher to serve as Co-Principal Investigator of the Center forHealthcare Knowledge Management.The Center is a interdisciplinary group ofmore than 15 core and affiliatedresearchers in the fields of medicine,social work, psychology, healtheconomics, demography, public health,and statistics, with an emphasis uponcare coordination and outcome

Positions Available and Announce-ments are $50 per 50 words forSGIM members and $100 per 50words for nonmembers. These feescover one month’s appearance inthe Forum and appearance on theSGIM Web-site at http://www.sgim.org. Send your ad, along with thename of the SGIM member spon-sor, to ForumAds@sgim.org. It isas-sumed that all ads are placed byequal opportunity employers.

PRACTICE INNOVATIONScontinued from page 11

measurement of progress were used to validate or re-direct actions.

What were two or three of the biggest challengesyou faced, and how did you overcome them?Undoubtedly, the largest challenge was limited re-sources in a cash-strapped public hospital. Orderingnew supplies and adequate staffing for new innovationsrequired constant negotiations. The hospital administra-tion accepted our premise of increased quality and abil-ity to meet the needs of Medicaid managed care, butincreasing telephone demand remains an issue. Impor-tantly, we were able to use this major structural changeto enlist multidisciplinary institutional support.

Do you have any data demonstrating the effectiveness of your innovation?Our large-scale practice overhaul resulted in several ob-jective improvements over a short period of time, includ-ing improvements in forms, patient flow via use offlagging system, rooming, and patient registration andtriage. Improvements in access have decreasing averagetime to next-available appointment by seven days and in-creased availability of non-urgent visits and phone refill.

We saw objective improvements in several indices,including patient and provider satisfaction, wait time,and billing; 92% of patients and 65% of physiciansagreed that “things have improved” in the PCC com-pared to the prior year. We also found that patientsspent an average of 36 minutes (20%) less time inclinic. Finally, our professional billing increased by ap-proximately 16%, largely due to decreased non-billablevisits and improved documentation on new forms.

Any closing thoughts?The PCC of Grady Memorial Hospital is one of thelargest ambulatory practices in Georgia, with approxi-mately 250 providers, including faculty and residentsfrom both Emory and Morehouse schools of medi-cine. The PCC is a hospital-based academic ambula-tory center that provides wide-ranging services tolargely urban, minority, and underserved communities,with less than 5% of our patients having commercialinsurance.

While we still have multiple challenges and limitedresources, we were able to utilize organizational leader-ship at all levels to support large-scale quality improve-ment initiatives and transform a large comprehensiveurban teaching practice. In doing so, we improved effi-ciency and increased billing. More importantly, we im-proved quality for a broad range of patients byproviding services like phone triage and telephonemedication refills that were previously unavailable.

SGIM

GM Outpatient Gross Charges

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$369,832.00

$285,687.00

$358,023.00

$412,263.00

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evaluation of complex chronic Illness.The Center works closely with the WarRelated Illness and Injury Study Center,and the Mental Health Service Line.

The position requires excellentcommunication and interpersonal skills,a track record in federally peer-reviewedgrant support, a strong publicationrecord, and mentorship experience.He/she must also hold the scientific,research and academic credentials toqualify for an academic appointment atNew Jersey Medical School or RobertWood Johnson Medical School. TheDepartment of Veterans Affairs is anEqual Opportunity Employer. Qualifiedcandidates (US Citizenship required)should submit a letter of interest andcurriculum vitae to:

15

VA New Jersey Health Care System,Human Resources (05), 385 TremontAvenue, East Orange, NJ 07018,Attention: Catherine Jordan Fax: (973) 395-7148 or e-mail: Catherine.Jordan1@va.gov.

The Department of Medicine, Sectionof Infectious Disease, seeks aphysician at the rank of AssistantProfessor of Clinical Medicine, who iscommitted to medical education andable to work with diverse students,trainees and colleagues. The selectedcandidate will be able to rotate throughinfectious disease outpatient clinics,inpatient medicine attending andconsults. There will be inpatientservice responsibilities involvingsubstantial resident and studentteaching. Seeking an enthusiastic,personable educator and clinician;scholarly interests encouraged. Tucsonoffers unsurpassed quality of life.Department of Medicine InterimChairman, Thomas D. Boyer, MDinvites interested candidates toforward Curriculum Vitae to

tboyer@deptofmed.arizona.edu,P.O. Box 245099, Tucson, AZ 85724.The University of Arizona is anEEO/AA-Employer-M/W/D/V.

Faculty PositionAcademic Clinician,

Division Of Internal Medicine

Department of Medicine at theJefferson Medical College and theThomas Jefferson University areseeking applications for a facultyposition in the Division of InternalMedicine. The successful candidate willhave responsibility for patient careprimarily in the outpatient setting,teaching and the opportunity for clinicalresearch. Applicants must hold amedical degree and be boardcertified/board eligible in the field ofInternal Medicine. Experience as anacademic clinician and interest inconducting clinical research are highlydesirable.

Located in Center City Philadelphia,Jefferson Medical College is one of theoldest and most highly respectedmedical schools in the U.S. Founded in1824, the Medical College is part ofThomas Jefferson University and isaffiliated with Thomas JeffersonUniversity Hospital and the JeffersonHospital for the Neurosciences.(Thomas Jefferson University is anequal opportunity/affirmative actionemployer.)

Please send curriculum vitae to:Barry Ziring, MD, Division Director,Division of Internal Medicine c/o Janet Desimone,janet.desimone@jefferson.edu

Society of General Internal Medicine2501 M Street, NWSuite 575 Washington, DC 20037www.sgim.org

SGIMFORUM