Inpatient Practice Outpatient Practice

You Can’t Get The Flu From A Flu Shot

vaccinationIt is flu shot season and my goal each year is to give more influenza vaccines in my clinic than any of the other pulmonologists. So, I offer it to all of my patients and continue to be amazed at how many of them decline because “Every time I get a flu shot, I end up getting the flu”. There is no live virus in a flu shot so you are just as likely to get the flu from a flu shot as you are likely to get pregnant by taking a birth control pill.

So why are patients so sure that they’ll get an infection from the flu shot. There are two main reasons. First, they may have had some muscle pain at the injection site or even some mild myalgia after a previous injection – this is a reaction to the vaccine and not an infection. If anything, it means that the vaccine is working because your immune system is mounting a response to it.

The other reason patients think that they get the flu from a flu shot is from superstition. The average American gets 2-4 upper respiratory infections (“colds”) per year. Lets just say it averages out to 3 colds per year. That works out to 1 cold every 17 weeks. In other words, statistically, 1 out of 17 patients will get a cold within a week of getting a flu shot purely by chance. Because they associate that cold with the flu shot, they incorrectly deduce that the vaccine caused the cold (which they equate to the flu). By the same argument, 1 out of 17 patients will get a cold within a week of Easter but you don’t hear patients telling you that they got the flu from the Easter bunny.

As it happens, if it wasn’t for influenza, I never would have been born. My grandmother’s first husband was one of the 21 million people who died of the “Spanish” influenza epidemic of 1918-1919. She then remarried to my grandfather so if her first husband hadn’t died of the flu, I wouldn’t be writing this post now. In the United States, about 23,000 people die of influenza each year; some years more and some years fewer, depending on the specific strains that go around that year.

It is particularly important for all healthcare workers to get vaccinated so that they don’t become a vector to transmit influenza to vulnerable patients. A few years ago, I admitted one of my patients with pulmonary fibrosis to the hospital with worsened shortness of breath. On admission, I did a bronchoscopy and sent PCR testing for influenza – it was negative. We determined that he was in heart failure and he improved over the days with diuresis. He lived alone and had no relatives so during his hospital stay, he had no visitors. After about a week, he became suddenly worse with hypoxemia and high fever. I repeated the bronchoscopy and this time, his influenza PCR was positive for influenza A. Based on the incubation period, he had to have acquired his influenza in the hospital. Since he didn’t have any visitors, he had to have acquired it from one of the doctors, nurses, or therapists. He never made it out of the hospital and died of his influenza in our ICU.

So, I’m pretty passionate about getting everyone who works in the hospital vaccinated for influenza each year. I don’t care so much whether they get influenza but I don’t want them transmitting it to a patient who would be more likely to die from it.

October 12, 2016

Inpatient Practice

A Consult Is Not A Sign Of Weakness

stop-consults-signTwo days ago I got an urgent email from one of our case managers asking if I could see a patient with asthma in the office ASAP. She was in the hospital with her third asthma exacerbation in 2 months and the case manager was trying to keep her from being admitted yet again. Although my practice is primarily interstitial lung diseases, I do try to help out with other pulmonary diseases when I can. I pulled her up on our electronic medical record and found that she had never had an inpatient pulmonary consult with any of her previous asthma admissions.

So, why in the world would a patient with a disease that is this difficult NOT have a consult by a specialist? I think it is a reflection of how residents are often trained. Going back to my own internal medicine residency, the mantra of the senior residents was that “A consult is a sign of weakness”, meaning that if you ordered a consult to an internal medicine specialist, it meant that you weren’t smart enough to handle that problem yourself. It wasn’t just my own specialty of internal medicine – a senior surgery resident told me that he didn’t get medical specialty consults because “A surgeon can do anything an internist can do plus we can operate”.

Over the years, those attitudes have become embedded in the culture of American medicine. What we forget is that the practice of medicine is a skill and like any skill, if you want to be good, the practice of medicine takes practice. Let me give you the analogy I use with my medical students. If you want to learn to ski, you can’t just read a bunch of books about skiing. You can’t just watch a bunch of videos of experienced skiers. And you can’t just strap on skis, go to the top of the slope and then try to get to the bottom over and over again. Truly learning a skill takes all three: didactic education, observation of skilled practitioners, and practice on your own.

In some residencies, the didactic education will be awesome, for example, many academic medical centers. In some residencies, there will be extraordinarily experienced clinicians that you will observe, for example, many community hospitals. In some residencies, the interns and residents are often on their own and get a lot of “sink or swim” experience taking care of patients independently, for example, some VA hospitals. Each resident needs a different optimal mix of didactics, observation, and practice to reach his or her potential. But all residents need each of them in some combination.

The thing that sets a specialist apart is that he or she has had a lot more practice with a specific group of diseases. And that practice can translate into more nuanced care, particularly for those difficult-to-treat cases. Furthermore, the specialist that sees the patient in the hospital is often the one who will be seeing that patient in the outpatient clinic and that translates into better continuity of care.

The literature confirms that inpatient consultation improves outcomes in difficult cases. A study presented at the Society of Hospital Medicine showed that inpatient cardiology consultation reduced the 30-day readmission rate for heart failure from 26% to 15%. A study of inpatient geriatrics consults showed a reduction in 6 & 8 month mortality rates. A study of inpatient palliative medicine consults showed a reduction in readmissions from 15% to 10%.

As a specialist who sees both inpatient and outpatient consultation, I don’t believe that there is any question too small or medical problem too minor and so I will never criticize another physician for requesting an inpatient consult. However, I will criticize a physician for not getting an inpatient consult when they should have. A patient with a medical illness who is being repeatedly readmitted is more complex and takes a lot more of the consultant’s time than a patient with the same disease but more minor symptoms who never gets admitted to the hospital. Insurance companies recognize that, for example, a level III inpatient new/consult visit has 3.86 work RVUs whereas a level V outpatient new/consult visit has 3.17 work RVUs. The implication is that it takes more time and more complexity to take care of that problem if it is bad enough to result in a hospitalization than if the patient is in an ambulatory office setting. So, I don’t want to see that really sick patient in the office, I want to see them in the hospital where I will have more time to do the evaluation and more diagnostic and therapeutic resources immediately available.

An inpatient who is challenging enough that they need to be seen by a specialist immediately after discharge is challenging enough that they should be seen by that specialist while they are still in the hospital. Because a consult is not a sign of weakness.

October 8, 2016

Inpatient Practice

PrEP Your Hospital To Prevent HIV

aids-209370_960_720I’ve been waiting for 35 years but finally, we have a way to prevent HIV infection. HIV and AIDS has been the defining illness in world health over the course of my career.

June 1981: I had just finished my first year of medical school the month that the CDC first reported an outbreak of a rare infection called Pneumocystis carinii in 5 young previously healthy gay men.

May 1983: I was finishing up my third year of medical school the month that the AIDS virus was first discovered.

July 1984: I was an intern in our MICU and treated the first patient with Pneumocystis pneumonia in our hospital, a hemophiliac man with AIDS acquired from a blood transfusion.

March & April 1987: I was finishing my residency when the FDA approved a Western blot test to diagnose HIV and approved AZT, the first medication to treat AIDS.

October 1987: I was a first year pulmonary fellow when I got sprayed in the eye by bronchoalveolar lavage fluid from a patient with AIDS in our ICU when a jet of BAL fluid managed to find a quarter inch gap between the goggles I was wearing and the bridge of my nose during a bronchoscopy. I was enrolled in a CDC study of mucosal exposure to HIV in healthcare workers and had to have an HIV test monthly for a year. I spent a year not knowing if I had acquired a terminal disease but fortunately, all 12 of my tests were negative.

Today, HIV is no longer an automatic death sentence like it was 30 years ago but it remains an enormous burden of morbidity, mortality, and financial cost throughout the world. Currently, 1 out of every 99 Americans will become infected with HIV at some time in their life. For gay hispanic men, it increases to 1 out of every 4 and for gay black men, it increases to 1 out of every 2. It can be controlled but it can’t be cured so our challenge is to prevent people from getting infected in the first place.

Now we can finally do it with PrEP: Pre-Exposure Prophylaxis. When used regularly and combined with condom use, up to 90% of HIV infections can be prevented. The drug is Truvada and it is a once-a-day pill. It isn’t cheap, about $1,500 per month. The challenge to all of us is to identify patients at risk of getting infected and then talk to them about prophylaxis.

Historically, disease prevention has been the purview of of the primary care office practice but if we are really going to be successful controlling HIV in our lifetimes, then we need to look beyond primary care and seek out other opportunities to identify at-risk patients and get them on PrEP. We often think of our emergency departments and our acute care hospitals as places where we treat disease and not where we prevent disease. But going forward, our emergency department physicians, our hospitalists, and our hospital-based nurses are going to be in a great position to at least ask patients about high-risk behaviors and then direct them to practitioners who can get them started on PrEP.

During my first year of pulmonary/critical care fellowship, I did 350 bronchoscopies and the overwhelmingly most common reason for bronchoscopy was AIDS with pneumonia. Those patients are all dead now as are dozens and dozens of others that I’ve cared for over the past 30 years. I’ll consider it an enormous success if I never have to see another man or woman die of AIDS again.

The bottom line is that our hospitals need to be prepared to PrEP.

September 26, 2016

Inpatient Practice

Variability Creates Vulnerability

As I mentioned in a previous post, we just had our every-3-year JCAHO site survey. One of the surveyors made a comment that “variability creates vulnerability” and that phrase really stuck with me. So what does this mean? Let me give you an example. If you get on a plane, the pilot is going to go through a series of pre-flight checks and the flight attendants are going to give you a short speech about how to fasten your seatbelt and what do do in the event of a water landing. I’ve heard it dozens of time from dozens of flight attendants and it is always the same. I’ve also flown with dozens of pilots and each time, the pilot’s check list is also the same.

Not everything in the hospital can be standardized but the more you can reduce variability in practice, the less variability in outcome that you will have. Let me give you three examples.

The best outcome in CPR happens if you do chest compressions 100-120 times per minute. In order to ensure that this happens, our doctors and nurses have to go through BLS (basic life support) or ACLS (advanced cardiac life support) every 2 years. However, in the excitement of a true cardiac arrest, it can be hard to avoid going either too fast or too slow. At our medical center, we have recently started to use devices attached to the patient during CPR so we can analyze the compression rate during the code after the fact. When we first started auditing codes, I was surprised how commonly the chest compression rate either exceeded 120 or fell below 100. It turns out that this is pretty common at every hospital in the world – one’s sense of time becomes very altered when one’s adrenal glands are pumping out adrenaline at an ounce a minute during a cardiac arrest situation. We found 3 strategies to ensure correct timing of compressions – 2 that are expensive and 1 that is cheap. There are now automatic CPR compression devices that will compress the chest at a set rate and these are pretty fool-proof; we have one of these in our ER. The newer generation of the CPR monitoring devices don’t just record the compression rate but they can give a real-time read-out of compression rate during CPR. The least expensive option is to down-load a free metronome app to your smartphone and set it at 110 beats a minute and then turn it on during CPR to synchronize your chest compressions.

Our hospitalists are expected to place central venous catheters (“central lines”) and most of them learn how to do it during their residency. But there can be a lot of variability of the quality of training from one residency to another and hospitals will use different central line kits with different supplies in those kits. So 2 new hospitalists may use very different technique to put a central line into the same right internal jugular vein. To solve this, we developed a checklist for each of the steps that we expect during a central line placement and we have our hospitalists get proctored placing central lines during their first 6 months of employment to be sure that no matter where and how they were trained in central line placement, that they place it using the same procedural steps at our hospital.

Making sure you have the correct patient in your operating room and that you perform that operation on the correct anatomic part of that patient seems like a pretty straight-forward thing but every week in the U.S., there is a wrong-site surgery. Imagine waking up after anesthesia to find out that your good hip just got replaced instead of your bad hip or that you got your gallbladder taken out rather than your appendix. One way to prevent this is the “time-out” where everyone involved in the procedure stops what they are doing and confirms the patient, the sedation plan, the anatomic location, the specific procedure, etc. But time-outs only work if everyone is paying attention and you don’t miss any steps in the time-out. Therefore, the time-out should be scripted and just as predictable as the flight attendants’ pre-flight speech, no matter if you are in an OR or an endoscopy suite and no matter who is assisting during the procedure.

You can’t standardize everything in your hospital but you can standardize a lot of things. So look around you and see what you can do to reduce variability in order to reduce your vulnerability to bad outcomes.

September 13, 2016

Inpatient Practice Life In The Hospital

The JCAHO Site Survey

We just went through our Joint Commission site survey and I have a few thoughts after doing this as a medical director. The Joint Commission for the Accreditation of Healthcare Organization (JCAHO or just “Joint Commission”) is the largest of several organizations that review and accredit hospitals in the United States. Hospitals pay the Joint Commission to do a top to bottom review of the hospital every 3 years and they look at everything from medical records, to equipment, to policies, and to the plumbing. The stakes are high: if you lose your accreditation, you can lose your ability to see Medicare and Medicaid patients. I’ve participated in about 2 dozen Joint Commission surveys between Ohio State and Select Specialty Hospitals in various medical director roles. This year’s survey was the first that I have gone through as a medical director for the whole hospital.

Each hospital will have an open “window” of time every 3 years that the Joint Commission can show up. The surveyors will show up unannounced at the hospital administration offices, typically on a Monday at 7:30 AM. The hospital then gives them access to all patient care areas, medical records, policies, etc. and the surveyors inspect… everything.

The number of surveyors can vary in number depending on the size of the hospital and other factors. This year, we had 8 surveyors: a social worker/counselor, a pediatric critical care nurse, a women’s health nurse practitioner, a former hospital chief nursing officer, an OR nurse, an infectious disease physician, a pediatric oncology nurse, and a former fire marshal. The social worker and the fire marshal were only here 1-2 days but the nurses and physician were here daily from Monday through Friday.

The survey consists of informal inspections and relatively formal sessions where one of the surveyors will sit down with a group of hospital leaders to discuss things like medication safety or credentialing. The real detailed part of the survey is when one of the surveyors goes to inspect a specific practice location. They may do this by deciding to go to the respiratory therapy department in the morning and the physical therapy department in the afternoon. They can also do this using a “tracer” method where they randomly pick a patient chart and then retrospectively follow that patient’s hospital course from when they first arrived in the emergency department to the operating room to the ICU to the nursing unit. They will inspect each location and interview staff at each location.

At our hospital, we have an accreditation specialist whose primary job is to ensure that we are always meeting accreditation standards for a variety of organizations that inspect us periodically. Each person who works in a hospital has a role to play during a Joint Commission site survey. As the hospital medical director, I found my role was a bit different than it was when I was a chief of internal medicine, MICU medical director, or PFT lab medical director. Here are some pointers:

  1. Read your bylaws and know what is in them.
  2. Know what is in your medical staff rules and regulations. I printed out a list of the titles and carried it with me.
  3. Know what your various hospital policies are. Again, I printed out a list of the titles to carried it with me.
  4. Have the policies and rules/regulations at hand. Ours are on our internal hospital internet site so I carried an iPad with me so I could pull them up if needed.
  5. Seek out the surveyors and introduce yourself. Accompany them when possible so you can answer questions.
  6. There is a penalty for guessing. You’ve spent your entire life taking multiple choice questions and knowing that if you don’t know the answer, you still have a 20% chance of getting the question right if you guess. With a Joint Commission survey, a wrong guess about something can be lethal. It is better to say that you don’t know and would have to check the files than it is to guess and be wrong.
  7. Get the medical staff involved. Too often, when they know that the JCAHO is in the hospital, the doctors will hide out in their offices or the doctor’s lounge. The surveyors really like to see the physicians engaged in the process so take time to introduce them.
  8. Walk through the hospital. The best way to keep your backyard tidy is to poop-scoop weekly all year round. But if you are hosting the annual office cook-out at your house, you still want to do a quick walk through the grass an hour before the party starts just to be sure. Same goes with a survey. Look for stuff stored in the hallways, unsecured medication drawers, dust on the sprinkler heads, and water stains on the ceiling tiles.
  9. Timing is everything. The surveyors are likely not going to be judging you on your choice of a statin in hyperlipidemia. It is just too subjective and hard to do in a short survey. What they can and will judge you on is whether you adhered to your policies. So, if your policy says you need an H&P on the chart less than 30 days before a surgery, that H&P better be dated < 30 days earlier. If your policy says that the anesthesia assessment needs to be done immediately before surgery, it better be timed before the start of the surgery.  If your policy says that a preliminary op note needs to be in the chart before the patient leaves the OR area, it better be timed before the time the patient is transported to the floor.
  10. It’s your policy, stick to it. Don’t make policies that the doctors can’t adhere to. A policy is what your doctors have to do every time, not what they should aspire to eventually do. If you put in your policy that your doctors need to assess the Mallampati class prior to doing procedural sedation, it has to be done and documented every single time.
  11. Everything expires. This is low-hanging fruit for a site surveyor, every bottle and package in your hospital has an expiration date whether it is a medication, a test strip, or a cleaning agent. Be sure that someone is checking them regularly. After our recent Joint Commission survey, I went through my refrigerator at home… there was salad dressing from 2011 in the back. Good thing they were inspecting the hospital and not my kitchen.

But the good news: we passed our survey. Next week, we have to start preparing for the next one.

September 9, 2016


Hospital Finances Inpatient Practice

How Many Patients Should A Hospitalist See A Day?

doctor-with-tablet-14619131467C0This is a burning question that every hospital CEO and medical director wants to know since most hospitals end up subsidizing hospitalists. And the answer is… it depends. Anyone who tells you categorically that the right number for every hospital is 15 patients a day is wrong.

What the hospital wants from the hospitalist is good value for the amount of money that the hospital pays to support the hospitalist. If the hospitalist is seeing too many patients per day, then there is a risk of bad things happening including medical errors, physician burn-out, increasing length of stay, worse patient satisfaction scores, and patient bottlenecks caused by later times of discharge. If your hospitalists are seeing too few patients a day, then you are not getting your money’s worth from them. Here are some of the variables that I look at when I’m deciding if our hospitalists are seeing the right number of patients.

  1. Patient case mix index (CMI). This is a pretty easy number to get from your hospital’s billing office. The higher the number above 1.0, the more medically complex the patients. It will give you an idea of the complexity of patients that the hospitalist is seeing and as a result, how much effort the hospitalist needs to put into the care of a given patient. Here is an example of 3 inpatient services from our own hospital. Service A is an attending-only (non-teaching) service that covers general medical admissions and the ICU – their CMI is 1.45. Service B is a teaching service with residents and a hospitalist attending that takes general medical admissions but does not cover the ICU – their CMI is 1.21. Service C is an attending-only (non-teaching) service that takes mainly cardiac admissions and a consequence, they have a high percentage of observation chest pain admissions – their CMI is 1.10.
  2. Teaching or non-teaching service. The ACGME limits the service census to 10 patients per intern. There is a time trade-off for hospitalists on teaching services: the residents will do a lot of the time-consuming work for the attending hospitalist but the hospitalist has to do uncompensated teaching time; in a healthy teaching service, these should balance out. A teaching service with a cap of 10 patients is rarely a full-day work for the attending hospitalist so he or she has to have some other income generating activity.
  3. Admitting service versus consultative service. Patients with medical illnesses requiring admission to the hospital are by definition sick. On the other hand, those coming in for an elective joint replacement generally have minimal medical conditions or their medical conditions are in good control. The hospitalist co-managing medically stable patients in for elective orthopedic surgeries can see considerably more patients per day than the hospitalist managing medical admissions coming in from the ER.
  4. Advanced practice providers. Physician assistants and nurse practitioners can allow a hospitalist to see more patients per day but they come at a cost, generally one-third to one-half the salary of a hospitalist. A physician assistant that allows a hospitalist to see 25 patients a day rather than 15 patients a day is probably worth it. However, if the use of a physician assistant only allows that hospitalist to see 18 patients per day rather than 15 patients per day, it may not be worth it.
  5. ICU or non-ICU. In the ICU, patients need to be re-assessed multiple times a day by the physician, there will be more bedside procedures to be done, and there will be more minute-by-minute orders to be placed. A hospitalist in the ICU may only be able to cover 12 patients a day whereas that same hospitalist may be able to take care of 20 patients a day on a general medicine nursing unit. That has to be tempered with the availability of additional consulting physicians – a general internal medicine hospitalist in the ICU may be able to see more patients if there is a critical care medicine consultant also rounding on the patients.
  6. Day shift versus night shift. There is a lot more work per patient on the census during the day than during the night. During the day, patients need to be rounded on, there are family meetings, and patients need to be discharged. During the night, the hospitalist does emergency admissions and deals with urgent/emergent inpatient issues. A night shift hospitalist may be able to cover 60 patients but a day shift hospitalist, only a quarter of that.
  7. Observation versus regular admission patients. This is a tricky one. On the one hand, observation patients are less medically complicated than regular admission patients and don’t have as much discharge complexity (need for home health, nursing homes, etc.). On the other hand, observation patients have a much shorter length of stay so a hospitalist with a lot of observation patients will be doing more time-consuming admissions and discharges per day than a hospitalist with mostly regular inpatient admissions. Currently in the U.S., the average hospital has 26% of their average patient hours being observation patients. Our hospitalist service that sees primarily cardiac patients has 50% of their patients in observation status; another hospitalist service that sees general medical admissions has 20% of their patients in observation status.
  8. Ease of documentation. If a hospitalist has a really good electronic medical record with vital signs, medication records, progress notes, lab reports, etc. then it can be far more efficient to take care of patients than if medical records are fragmented. For example, at one hospital in our community, the physician progress notes are handwritten in a paper chart, the vital signs and medication records are on one computer system, and the lab and radiology reports are on another computer system. It is neither possible or safe for a hospitalist to see as many patients in this environment as they can in a hospital with a single, integrated electronic medical record.
  9. Patient captivity in the electronic medical record. By this, I mean whether the hospital and the primary care physicians caring for the patients who get admitted to that hospital use the same electronic medical record. If they do, then it is much easier for the hospitalist to do admissions and discharges since much of medical history documentation is already in the electronic medical record. It is much faster to do an H&P if you can draw in the entire past medical, surgical, family, and social history plus all of the patient’s current medications and doses with one click on the computer rather than having to manually enter all of the information.
  10. Non-clinical duties. A hospitalist that is spending 2 hours a day in committee meetings cannot see as many patients per day as a hospitalist who has no committee assignments.
  11. Shift duration. A hospitalist working a 12-hour shift may be able to see 20 patients a day (1.7 encounters per hour) comfortably but that same hospitalist working an 8-hour shift may only be able to see 14 patients a day (1.7 encounters per hour) comfortably. Shift duration also affects the number of shifts per month you should expect your hospitalists to work: if you expect your hospitalists to work 2,300 hours per year, then that is 16 12-hour shifts per month but 24 8-hour shifts per month.
  12. Hospitalist experience. All hospitalists are not equal. A new hospitalist right out of residency is not going to be as efficient and see as many patients as a hospitalist with 20 years of practice experience. High hospitalist turn-over means more new physicians who cannot see as many patients per day as experienced hospitalists. If you force your hospitalists to see too many patients per day, they will quit and you will end up with excessive hospitalist turn-over.
  13. Hospital geography. It can take a hospitalist caring for 15 patients on 6 different nursing stations more time per day to manage than a hospitalist caring for 20 patients on a single nursing station.
  14. Encounters versus census. We often focus on the hospital midnight census to measure hospital capacity. But that only measures the patients who are in a bed at midnight and over the course of the day, there is going to be bed turnover as patients are admitted and discharged. If the patient length of stay is long, then the midnight census will be close to the number of daily patient encounters per physician. If the length of stay is short, then the hospitalists will have a lot more patient encounters per day than the midnight census.
  15. Census variability. Too often, we look at census averages and although this is useful, it doesn’t tell the whole story. For example, last Monday, we had 109 medical/surgical beds occupied and by Thursday we had 140 – that is a 31-patient swing in just 3 days. This means that the hospitalist services all had more patients per hospitalist on Thursday than they did on Monday. So, if your hospitalist census averages 15 patients per physician but the census fluctuates between 8 and 25, there are going to be days that the hospitalists will have a hard time safely caring for those higher numbers of patients. If there is not a surge plan to bring in “risk call” hospitalists on those high census days, you may need to settle for a lower average daily census per hospitalist in order to accommodate those unpredictable days when the hospital census is usually high.
  16. RVU productivity. This is also a tricky metric because it does not capture all of the work done by a single hospitalist but at least it gives you a ballpark comparative to determine if your hospitalist program as a whole is meeting productivity benchmarks. The MGMA reports that the median total RVUs generated by a hospitalist is 5,900 and the work RVUs are 4,100. These numbers are affected by day versus night shift and other variables.
  17. Robustness of case management. Case management has to happen whether or not a hospital has case managers. A hospitalist who has to do a lot of the discharge planning because of a lack of case managers cannot see as many patients per day.
  18. The local market. If your town has several competing hospitals, then each hospital will be competing with the others for hospitalist and if the hospital down the street has an expectation of 15 patients per day and your hospital’s expectation for the same patient population is 20 patients per day, then you are going to lose valuable hospitalists.
  19. The patient demographic. If your hospital mainly sees patients with good commercial insurance and good primary care providers, then it is easier for the hospitalist to focus on the acute problem that brings the patient into the hospital and it is easier to make discharge arrangements. On the other hand, if you have a high percentage of uninsured or Medicaid patients, then the hospitalist taking care of a patient with pneumonia is likely going to also be spending time tuning up that patients diabetes, heart failure, or hypertension since the only time the patient sees a doctor each year is when he/she is in the hospital.

So what does a medical director or hospital CEO do? I recommend starting with an assumption of 15-18 patients per hospitalist and then working up or down from that number based on the unique features of your own hospital, community, and hospitalist program structure by taking into account the variables I mention above.

August 13, 2016

Inpatient Practice

Pain, The Most Regulated Vital Sign

PainIn 1996, the American Pain Society introduced the concept of “pain as the 5th vital sign” in order to increase awareness of insufficiently treated pain. As a consequence, in 2001, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) added a requirement for healthcare providers to ask every patient about their pain in order to avoid under treatment of pain while in the hospital. In 2006, the Center for Medicare and Medicaid Services required hospitals to ask patients questions about how well patients reported that their pain was treated as part of publically reported CMS hospital quality scorecards. But more recently, for too many patients, attempts to control chronic pain has resulted in opioid addiction. So who is to blame: the JCAHO? Medicare? Hospitals? The pharmaceutical industry? Individual physicians? Well, the answer is… all of the above.

The American Pain Society’s “pain as the 5th vital sign” initiative came out at a time before palliative medicine had really emerged in the United States. Prior to the mid-1990’s cancer pain management was frequently inadequate and there were limited medication options for treating chronic pain. Oxycontin was approved by the FDA in 1995 and released in 1996, the same year of the “pain as the 5th vital sign” initiative. Oxycontin was initially marketed as an “addiction-proof painkiller”. The combination of a powerful new long-acting oral opioid plus the messaging that physicians have not been treating pain adequately rapidly led to excessive prescription of oxycontin which recently has had sales of over $2 billion per year. And the “addiction-proof” opioid turned out to not be addiction-proof at all.

Next enter the JCAHO which publishes standards that hospitals are evaluated on during their every three year hospital site surveys. One of the standards addresses how well the hospital deals with patients’ pain:

JCAHO Standard PC.01.02.07 The hospital assesses and manages the patient’s pain:

  1. The hospital conducts a comprehensive pain assessment that is consistent with its scope of care, treatment, and services and the patient’s condition.
  2. The hospital uses methods to assess pain that are consistent with the patient’s age, condition, and ability to understand.
  3. The hospital reassesses and responds to the patient’s pain, based on its reassessment criteria.
  4. The hospital either treats the patient’s pain or refers the patient for treatment.

It is point number 4 that has led hospitals and physicians to overzealously treat pain. Because a large number of hospitals do not have easy access to inpatient pain management specialists, many feel backed into a corner by point #4, interpreting it as saying that if you do not have a pain service, then you have to treat the patients pain… period. Needless to say, hospitals are strongly motivated to err on the side of overtreatment of pain rather than risk undertreatment which could result in penalties levied by the JCAHO.

Medicare also weighed in on pain management. In 2002, it created the HCAPS patient satisfaction survey that was then implemented in 2006 and the results became publicly available in 2008. The HCAHPS survey asks patients 32 questions about their hospitalization. The Center for Medicare and Medicaid Services requires hospitals to administer the survey to patients and then CMS uses the results of that survey as part of the “Hospital Compare” scorecards on the CMS website. In an effort to measure the quality of care provided by physicians, many health systems also use the HCAHPS survey results for individual physician evaluation and in many health systems, physician bonuses and compensation is tied to how well the physician scores on the HCAHPS survey. There are three pain-related questions in the HCAHPS survey:

  1. Did you need medicine for pain? 
    1. Yes
    2. No
  2. During this hospital stay, how often was your pain well controlled?
    1. Never
    2. Sometimes
    3. Usually
    4. Always
  3. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?
    1. Never
    2. Sometimes
    3. Usually
    4. Always

It is easy to see how physicians, whose income is tied to how well patients’ pain is controlled, will do everything they can to eliminate pain, including prescribing excessive opioids since there is no penalty for overtreatment but a financial penalty for undertreatment.

So where does that leave us? In Ohio alone, 3/4 of a billion pain pills are prescribed each year – that is 65 pills for each Ohioan. 20% of chronic opioid users are addicted. The State Medical Board of Ohio has implemented several rules and guidelines to reduce the abuse of prescription opioids including an opioid prescription limit of 3 days for pain associated with emergency department or acute care hospital visits, the use of signed “pain contracts” by patients receiving opioids for > 3 months, regular interrogation of the State’s database of opioid prescriptions by outpatient pharmacies for opioid prescriptions > 7 days, and periodic urine drug testing.

One of our medical center’s trauma surgeons, Dr. Danny Eiferman along with one of our pharmacists, Lisa Mostafavifar, have been champions for the responsible use of opioids. When used for brief periods of time in post-op and injured patients, these medications can greatly improve patients’ quality of life. And when used for patients with chronic cancer pain, they can also improve the quality of life. But when overused, opioids can ruin a patient’s life. Here are some concrete recommendations from Dr. Eiferman and Lisa Mostafavifar:

  1. Set realistic patient expectations. A 30% reduction in pain intensity should be the goal (for example, a reduction from 10 to 7 on a pain scale). Complete elimination of pain is rarely achievable and should not be what we tell the patients to expect.
  2. Non-steroidal anti-inflammatory drugs and acetaminophen are often as or more effective than opioids in many types of pain.
  3. Multi-modality therapy (massage, physical therapy, etc.) is effective.
  4. Escalating doses of opioids often does not reduce pain scores.
  5. The function of opioids declines after 6 weeks of use.
  6. A PCA pump may be appropriate if repeated doses of a parenteral opioid are anticipated.

Pain management requires a careful balance of meeting patients’ often very real pain needs and avoiding contributing to the epidemic of chronic opioid pain pill addiction. Each patient is unique and has to be evaluated on an individual basis. Here are some of the general principles that I apply when counseling physicians about opioid prescribing:

  1. If you are an outpatient physician who does not frequently prescribe opioids and are not familiar with the risks and legal requirements, then do not prescribe them for chronic use.
  2. If you prescribed opioids for what should be a self-limited condition and the patient continues to request opioids, that should be a red flag.
  3. Make sure you are adhering to your state medical board’s requirements for opioid prescription.
  4. If you are not a pain management specialist and your patient asks for opioids for > 3 months, get a pain management consult.
  5. If you are an inpatient physician and a patient with known or suspected drug abuse needs inpatient opioids, be sure that they are given by directly observed therapy, preferably in liquid form, to prevent drug hoarding.
  6. If you admit a patient who reports being on chronic opioids confirm this with their primary care provider before either increasing their maintenance drug or discontinuing it.
  7. If you believe that an inpatient who reports being on chronic opioids is abusing or selling their prescription medications and you feel compelled to stop their opioids while the patient is an inpatient, then do so in conjunction wth an addiction medicine consultation.
  8. When considering discontinuing chronic opioids, in either the inpatient or outpatient setting, always consider the risk of opioid withdrawal in the setting of the patients underlying medical condition and if there is concern that withdrawal could be dangerous, then obtain consultation with an addiction specialist to minimize the risk of harm to the patient during opioid withdrawal.
  9. If you have a patient who is frequently admitted for pain management (for example, a patient with sickle cell anemia), develop a patient-specific pain management plan that can be easily located to guide medication prescription each time that patient is admitted.

Ten years ago, the opioid pendulum swung too far one way in one direction. More recently, it has swung too far in the opposite direction. As leaders in medicine, we must strike a balance in the pendulum to promote responsible use of these medications that have both the potential to relieve great suffering but also the potential to cause great harm.

August 10, 2016



Inpatient Practice

Medicare’s Stars Don’t Shine Brightly

starThis week, Medicare released its new hospital rating system, The Hospital Compare Overall Hospital Quality Star Ratings. Using this system, Medicare rates hospitals by their quality using a 5 star system with 1 representing the lowest quality hospital and 5 representing the highest quality hospital. In reviewing the methodology, I believe that Medicare has failed epically.

The rating is based on 64 quality measures that Medicare tracks for all hospitals in the United States. Because not all 64 measures will apply to every hospital, Medicare only uses those applicable to a given hospital so that for any given hospital, the quality measures reviewed can be as many as 64 but as few as 9 with an average of 40 per hospital. The full listing of all of the specific quality measures can be found on the CMS website here. The 64 quality measures are grouped into 7 categories including:

  1. Mortality
  2. Safety of care
  3. Readmissions
  4. Patient experience
  5. Effectiveness of care
  6. Timeliness of care
  7. Efficient use of medical imaging

The Comprehensive Methodology Report published by Medicare details exactly how these quality measures are incorporated into the final rating. I would challenge anyone reading this blog to read the report and try to understand it. It is incomprehensible.

From the ratings, 2.2% of U.S. hospitals got a 5-star rating, 20.3% a 4-star rating, 38.5% a 3-star rating, 15.7% a 2-star rating, 2.9% a 1-star rating, and 20.4% were unrated.

So here is the problem. By using mortality measures as one of the main determinants of the rating system, hospitals that take care of sicker patients are going to be ranked lower; for example, tertiary care hospitals, those that have a high percentage of their inpatients admitted through emergency departments, and those that do higher risk procedures such as coronary artery bypass and graft surgery will be ranked lower simply because of the population of patients that they care for.

Even more concerning is the use of 8 quality measures that have to do with readmissions. It is well-established that risks for readmission to the hospital within 30 days of discharge is correlated with lower income patients, older patients, socioeconomically disadvantaged racial groups, and availability of primary care physicians in the community. Hospitals that care for these patients will have a lower ranking.

When the rankings of U.S. hospitals was released this week, there were some surprising (or maybe not so surprising) findings. Hospitals that do not manage complex patients and those that do not do high-risk procedures and surgeries fared very well and were highly ranked. Hospitals that care for the underserved and care for more medically complex patients fared poorly and were ranked very low. As an example, academic teaching hospitals were uniformly ranked low whereas non-teaching hospitals (which tend to manage less medically complicated patients) were ranked quite highly. The Ohio State University Medical Center came in at a 3-star rating which puts it among the top-performing academic medical centers in the nation but I know those other academic medical centers and they are not poor quality hospitals.

Hospital star rating Medicare

So what does this mean to a hospital that would like to have a high Medicare star ranking? Well, in the spirit of Jonathan Swift’s treatise “A Modest Proposal”, here are the steps a hospital can take to improve its Medicare ranking:

  1. Eliminate the emergency room. You must avoid sick patients from being in your hospital at all costs and since sick patients come to the emergency room, if you don’t have one, those undesirable patients will go elsewhere.
  2. Do not allow any patient > 65 years old to be admitted to your hospital. First, if the patients are not over 65, they likely won’t have Medicare so Medicare will not track them and second, patients over 65 are more likely to be sicker so you do not want them in your hospital.
  3. Do not admit anyone with an income of less than $24,250 per year. This is the Federal poverty limit for a family of 4 in the United States. Many studies have shown that patients with lower income have higher 30-day readmission rates. Therefore, make them go elsewhere.
  4. Do not admit patients who belong to socioeconomically disadvantaged races. These patients have also been shown to have higher 30-day readmission rates to the hospital. African Americans, Hispanic Americans, and Native Americans should be told to go elsewhere if your hospital wants to be ranked higher by Medicare.
  5. Stop taking trauma patients and close your trauma center if you have one.
  6. If you have an obstetric unit, only take care of wealthy women. Since one of the measures is “Elective delivery prior to 39 completed weeks gestation” and it is known that socioeconomically disadvantaged women have a higher premature birth rate, a hospital wanting to improve its Medicare ratings should not deliver disadvantaged women. Preferably, your hospital should only deliver upper class, non-smoking, caucasian women between the ages of 18-35 with a body mass index of < 30 and no diabetes, no prior history of pre-eclampsia, and no history of being physically or sexually abused. Do not permit twins or triplets to be delivered at your hospital.
  7. Fire anyone who works in your hospital who refuses to get a flu shot. “Healthcare personnel influenza vaccination” is one of the quality measures so if your nurses or doctors don’t get a vaccine, get rid of them in order to improve your rating.
  8. Get rid of all trainees such as residents, medical students, and fellows since hospitals with trainees have a substantially worse rating by Medicare’s criteria.
  9. Above all, do not ever, ever, ever admit patients with chronic pain such as patients with sickle cell anemia or chronic wounds. “Pain management” is one of the quality measures and specifically it revolves around how well pain was controlled. As an alternative, an equally effective strategy is to prescribe ad lib oxycontin to any patient who asks for it in order to improve the pain questions on the Medicare-required patient questionaires.

Obviously, this is absurd. Hospitals exist to take care of sick patients and those hospitals that care for the sickest patients and those that are the most socioeconomically disadvantaged have been unfairly penalized by the new Medicare star ranking system. At best, this system is flawed. At worst, it is discriminatory on a racial, economic, and age basis.

July 29, 2016

Hospital Finances Inpatient Practice

The Three Most Valuable Specialists In Your Hospital

book and stethescopeFrom reading the title of this post, you’re probably thinking that I am going to list some surgical specialties, interventional cardiology, or gastroenterology since these specialties bring in financially lucrative procedure volume to the hospital. So what I am going to say is going to surprise you. I’m going to make the argument that the 3 most valuable specialists in your hospital are geriatrics, infectious disease, and nephrology. I know what’s going through your mind right now: “What in the world is he thinking about?”. Well, let me make my case and then you decide. And it all starts with CPT.

CPT codes, or the Current Procedural Terminology codes, are the coding numbers that are assigned to every service and procedure that a physician does, from an office visit to an appendectomy. So for example, CPT 99221-99223 code for the 3 different levels of new inpatient encounters and CPT 99251-99255 code for the 5 different levels of inpatient consultation encounters. For decades, those consultation codes charged by a specialist paid more than the standard new patient encounter codes that would be charged for an admission history and physical examination by a generalist. This makes sense – if you are a specialist and providing a specialty consult opinion drawing from your additional years of training and experience, you should be paid more than the generalist doing a standard history and physical exam.

But on January 1, 2010, Medicare got rid of the consultation codes and required specialists to use the same CPT codes that the generalists were using for the admission history and physical exam. The net result of that decision was that cognitive specialists (i.e., those that do not have a procedure that they do) saw a significant drop in their income compared to the procedural specialists (i.e., those that do a procedure, like cardiac stress testing or colonoscopy). The three subspecialties that were affected the most were infectious disease, nephrology, and geriatrics.

Every year, the Medical Group Management Association (MGMA) publishes the starting salaries for physicians in their first year after completing training. In the past, specialists made more money than generalists. It makes sense… if you do an extra 2-3 years of training as a subspecialty fellow, you should expect a return on investment for that training and so you should expect a higher salary. But since the elimination of the consult codes by Medicare, some specialists, namely those that don’t involve doing lucrative procedures, have seen their salaries drop to the point that there is no longer any return on the investment of the extra years of subspecialty fellowship. Here is the most recent data from the annual MGMA salary survey from 2015 (based on data from 2014).

Physician salary


With general internal medicine, family practice, and hospitalist medicine, all you need is 3 years of residency and you are ready to start practicing. For all of the other specialties, you have to do 2-3 years of additional fellowship training. For infectious disease and nephrology, there is no salary advantage to doing those additional years of fellowship training (geriatrics is not listed in the MGMA report but their salary is typically similar to general internal medicine). In fact, the cost of doing the additional years of fellowship training is that you are going to make less than a family physician or a hospitalist who stopped after 3 years of residency.

For any of my colleagues in academic medicine who are looking at these numbers and saying, “I don’t make anywhere near that amount even though I’ve been practicing for years”, relax. The MGMA data is largely derived from private practice physicians and not academic physicians and as has always been the case, you make a lot more in private practice than you do in academics.

All of this has not gone unnoticed by medical students and residents when choosing a subspecialty. Recently, the National Residency Match Program released the results of the 2016 resident and fellow match. The results paint a frightening picture for the future of the cognitive specialties.


This graph shows the percentage of available fellowship positions that were filled by graduates of American medical schools (blue) and the percentage of fellowship positions filled by all applicants, including foreign medical graduates (orange). In keeping with the starting salary data, residents just are not going into geriatrics, nephrology, or infectious disease. There is simply no return on the time investment of doing a fellowship.

So what does this mean for hospital medical directors? Geriatricians, nephrologists, and infectious disease specialists are going to become increasingly scarce. It is going to be harder and harder to recruit these specialists. Of equal concern, there is a danger that the best and smartest residents will be drawn to the other specialties, resulting in an overall drop in the caliber of the new cognitive specialists in future years compared to past years.

We are fortunate at our hospital. The Director of the Division of General Internal Medicine and the Chairman of Internal Medicine have placed a high value on geriatrics. We have great nephrologists and one of the premier interventional nephrology programs in the country. And 2 years ago, the Director of the Division of Infectious Disease recruited one of the best clinicians I know as our hospital’s lead infectious disease specialist and director of hospital epidemiology.

If you have a good geriatrician, a good nephrologist, or a good infectious disease specialist, take good care of him or her because he or she is going to be hard to replace. And when you have strategic planning meetings with your hospital business leaders, speak up for these specialties because hiring them now before their supply drops further is going to be a good long-term business decision. For medical students who have always dreamed of a career in one of these specialties, take heart, because in a few years the invisible hand that governs the law of supply and demand in capitalism will cause their salaries to rise again in the future.

July 23, 2016

Inpatient Practice

The Ten Commandments Of Consultation

Thirty years ago, Dr. Lee Goldman wrote an article titled “Ten Commandments for Effective Consultation”. I’ve taken some liberties with his recommendations in the context of practice in an era of the electronic medical record.

  1. No consult question is too small. If a physician requests a consultation, it is usually because he or she believes that they and their patient will benefit from your expertise.
  2. Weekends are the same as weekdays. Patients should expect the same level of physician care no matter what day of the week they happen to be in the hospital. New consults on Saturdays and Sundays should be seen promptly.
  3. Follow up your test results. Advising what test to order is one half of your responsibility as a consultant. Interpreting that test result in the context of the patient’s illness is the other half. As a consultant, you share responsibility for the tests that you recommend to the primary service.
  4. A consult is a gift. In the business of medicine, consultants survive by providing consultation. Refusing a consult is like refusing a birthday present.
  5. It’s not a request for consultation, it’s a request for collaboration. The admitting physician may not see your note until the next day and so tests or important medication changes may not be ordered for >24 hours unless you ensure that they happen promptly. On teaching services (with residents), call the resident to let him/her know what you want done. On non-teaching services, enter your own orders for tests or medication changes for the problem that you were asked to assist with or call the attending physician with your recommendations. Inpatient medicine has become a team sport and the patient who wins is the one who has the strongest team of physicians, not just a single strong player.
  6. Availability trumps ability. A consultant succeeds by providing the best customer service and the physician requesting consultation is the customer. Consults requested before 10:00 AM should be seen that day. Seeing patients promptly and being available by phone/pager to the primary service is best practice. If you need your car’s oil changed, would you give your business to the garage that is only open from 9 AM to noon or would you go to the garage that is open from 7 AM to 7 PM?
  7. The discharge is the most dangerous procedure in medicine. As a specialist, you are in the best position to know what is needed in follow up. Assist by scheduling outpatient testing or clinic appointments. Give specific recommendations for medication doses and duration after discharge (especially antibiotics). If monitoring labs are necessary for the treatment that you have recommended, either have those labs sent to you for action/review or make sure that there is a clear hand off to another physician who will take responsibility for those lab test results.
  8. Answer the question that you are asked. You may find additional medical problems that need to be addressed but never forget to respond to the initial question.
  9. Distillation is more important than regurgitation. With electronic medical records, it is easy to import pages and pages of test results. The physician requesting your consultation is not requesting you to restate all of the data retrievable from the computer, that physician is requesting your analysis of all of the data. Make your assessment and analysis easy to locate in your note. When it comes to background data in your consultation note, in general, less is more.
  10. Don’t be a one and done. Your initial impression and recommendation are valuable but your follow up of those recommendations is often even more valuable. See your consults daily until the problem that you were asked to address is resolved or stabilized. Consult follow ups should be seen daily, whether that day is a weekday or a weekend.
  11. And the Golden Rule of consultation: Consult unto your neighbor as you would want your neighbor to consult unto you. Enough said.

July 22, 2016