Chad T. Whelan

Evaluating the teaching of evidence based medicine: conceptual framework

Although evidence for the effectiveness of evidence based medicine has accumulated, there is still little evidence on what are the most effective methods of teaching it.

Worklife and Satisfaction of Hospitalists: Toward Flourishing Careers

ABSTRACTBACKGROUNDThe number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians.OBJECTIVEDetermine current satisfaction levels among hospitalists.DESIGNSurvey study.METHODSA national random stratified sample of 3,105 potential hospitalists plus 662 hospitalist employees of three multi-state hospitalist companies were administered the Hospital Medicine Physician Worklife Survey. Using 5-point Likert scales, the survey assessed demographic information, global job and specialty satisfaction, and 11 satisfaction domains: workload, compensation, care quality, organizational fairness, autonomy, personal time, organizational climate, and relationships with colleagues, staff, patients, and leader. Relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity were explored.RESULTSThere were 816 hospitalist responses (adjusted response rate, 25.6%). Correcting for oversampling of pediatricians, 33.5% of respondents were women, and 7.4% were pediatricians. Overall, 62.6% of respondents reported high satisfaction (≥4 on a 5-point scale) with their job, and 69.0% with their specialty. Hospitalists were most satisfied with the quality of care they provided and relationships with staff and colleagues. They were least satisfied with organizational climate, autonomy, compensation, and availability of personal time. In adjusted analysis, satisfaction with organizational climate, quality of care provided, organizational fairness, personal time, relationship with leader, compensation, and relationship with patients predicted job satisfaction. Satisfaction with personal time, care quality, patient relationships, staff relationships, and compensation predicted specialty satisfaction. Job burnout symptoms were reported by 29.9% of respondents who were more likely to leave and reduce work effort.CONCLUSIONSHospitalists rate their job and specialty satisfaction highly, but burnout symptoms are common. Hospitalist programs should focus on organizational climate, organizational fairness, personal time, and compensation to improve satisfaction and minimize attrition.

BRIEF REPORT: Reducing Inappropriate Usage of Stress Ulcer Prophylaxis Among Internal Medicine Residents: A Practice-Based Educational Intervention

AbstractBACKGROUND: Many inpatients receive stress ulcer prophylaxis (SUP) inappropriately. This indiscriminate usage increases costs and avoidable side-effects. Practice-based learning and improvement (PBLI) methodology may improve compliance with published guidelines. OBJECTIVE: To investigate the response of internal medicine residents to an educational intervention regarding SUP. DESIGN: A prospective, pre and postintervention cohort study using an educational intervention based on PBLI. PATIENTS: Three groups of consecutively admitted patients (1 group preintervention and 2 groups postintervention) on the medicine ward at a University Hospital. MAIN OUTCOME MEASURE: Rates of inappropriate SUP prescription and discharge with an inappropriate prescription. RESULTS: One month after the intervention, inappropriate prophylaxis was significantly decreased (59% pre, 29% postintervention, P<.002). The rate of discharge with an inappropriate prescription also decreased, but was not significant (25% pre, 14% postintervention, P=.14). In the 6-month postintervention cohort, inappropriate SUP remained lower (59% pre, 33% postintervention, P<.007). The rate of discharge with an inappropriate prescription was also significantly lower (25% pre, 7% postintervention, P<.009). CONCLUSION: Practice-based learning and improvement can improve compliance with published guidelines, and change practice patterns. After the intervention, both inappropriate prophylaxis and inappropriate prescriptions upon discharge were reduced. Importantly, the intervention was sustained, transmitted across academic years to a new class of interns who had not directly experienced the intervention.

Upper versus lower gastrointestinal bleeding: A direct comparison of clinical presentation, outcomes, and resource utilization

PURPOSE To compare prevalence, clinical outcomes, and resource utilization between subjects with lower gastrointestinal bleeding (LGIB) and upper gastrointestinal bleeding (UGIB). METHODS Using administrative data, patient surveys, and chart abstraction, comparisons between subjects admitted with LGIB and UGIB were made by employing bivariate and multivariate statistics. RESULTS A total of 367 subjects were identified, LGIB = 187 and UGIB = 180. Subjects with UGIB compared to LGIB had greater admission hemodynamic instability including tachycardia and orthostasis but clinical outcomes were similar. In multivariate analyses, no significant differences were observed for in-hospital mortality transfer to the intensive care unit (ICU) or 30-day readmission rate. Resource utilization was similar in UGIB and LGIB, including mean costs, length of stay, and number of endoscopic procedures. CONCLUSIONS Unlike prior studies, this direct comparison of LGIB to UGIB identified more similarities than differences with similar prevalence rates, clinical outcomes, and resource utilization, suggesting that the epidemiology of gastrointestinal bleeding may be changing.

Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care.

A significant portion of hospital care involves elderly patients who have frequent and severe disease presentations, higher risk of iatrogenic injury during hospitalization, and greater baseline vulnerability. These risks frequently result in longer and more frequent hospitalizations. The frailty and complication rates of the elderly population underscore the importance of hospital-based programs of education and screening for cognitive and functional impairments to determine risk and needed additional care and services during hospitalization and at discharge. In addition, physicians are needed to take the lead in instituting programs of prevention and improving the systems of care. It is such a multi-tiered approach, with interventions in the areas of education, screening, prevention, and systems of care improvements, that is needed to improve the clinical care and outcomes of the hospitalized elderly patient.

A matter of priorities? Exploring the persistent gender pay gap in hospital medicine.

BACKGROUND Gender earnings disparities among physicians exist even after considering differences in specialty, part-time status, and practice type. Little is known about the role of job satisfaction priorities on earnings differences. OBJECTIVE To examine gender differences in work characteristics and job satisfaction priorities, and their relationship with gender earnings disparities among hospitalists. DESIGN Observational cross-sectional survey study. PARTICIPANTS US hospitalists in 2010. MEASUREMENTS Self-reported income, work characteristics, and priorities among job satisfaction domains. RESULTS On average, women compared to men hospitalists were younger, less likely to be leaders, worked fewer full-time equivalents, worked more nights, reported fewer daily billable encounters, more were pediatricians, worked in university settings, worked in the Western United States, and were divorced. More hospitalists of both genders prioritized optimal workload among the satisfaction domains. However, substantial pay ranked second in prevalence by men and fourth by women. Women hospitalists earned

The role of the hospitalist in quality improvement: Systems for improving the care of patients with acute coronary syndrome

14,581 less than their male peers in an analysis adjusting for these differences. CONCLUSIONS The gender earnings gap persists among hospitalists. A portion of the disparity is explained by the fewer women hospitalists compared to men who prioritize pay.

Person‐job fit: An exploratory cross‐sectional analysis of hospitalists

Quality improvement (QI) initiatives for systems of care are vital to deliver quality care for patients with acute coronary syndrome (ACS) and hospitalists are instrumental to the QI process. Core hospitalist competencies include the development of protocols and outcomes measures that support quality of care measures established for ACS. The hospitalist may lead, coordinate, or participate in a multidisciplinary team that designs, implements, and assesses an institutional system of care to address rapid identification of patients with ACS, medication safety, safe discharge, and meeting core measures that are quality benchmarks for ACS. The use of metrics and tools such as process flow mapping and run charts can identify quality gaps and show progress toward goals. These tools may be used to assess whether critical timeframes are met, such as the time to fibrinolysis or percutaneous coronary intervention (PCI), or whether patients receive guideline-recommended medications and counseling. At the institutional level, Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) is an initiative designed to improve outcomes in elderly patients who are at higher risk for adverse events during the transition from inpatient to outpatient care. BOOST offers resources related to project management and data collection, and tools for patients and physicians. Collection and analysis of objective data are essential for documenting quality gaps or achievement of quality benchmarks. Through QI initiatives, the hospitalist has an opportunity to contribute to an institutions success beyond direct patient care, particularly as required for public disclosure of institutional performance and financial incentives promoted by regulatory agencies.

Applying Classification Trees to Hospital Administrative Data to Identify Patients with Lower Gastrointestinal Bleeding.

BACKGROUND Person-job fit is an organizational construct shown to impact the entry, performance, and retention of workers. Even as a growing number of physicians work under employed situations, little is known about how physicians select, develop, and perform in organizational settings. OBJECTIVE Our objective was to validate in the hospitalist physician workforce features of person-job fit observed in workers of other industries. DESIGN The design was a secondary survey data analysis from a national stratified sample of practicing US hospitalists. MEASURES The measures were person-job fit; likelihood of leaving practice or reducing workload; organizational climate; relationships with colleagues, staff, and patients; participation in suboptimal patient care activities. RESULTS Responses to the Hospital Medicine Physician Worklife Survey by 816 (sample response rate 26%) practicing hospitalists were analyzed. Job attrition and reselection improved job fit among hospitalists entering the job market. Better job fit was achieved through hospitalists engaging a variety of personal skills and abilities in their jobs. Job fit increased with time together with socialization and internalization of organizational values. Hospitalists with higher job fit felt they performed better in their jobs. CONCLUSIONS Features of person-job fit for hospitalists conformed to what have been observed in nonphysician workforces. Person-job fit may be a useful complementary survey measure related to job satisfaction but with a greater focus on function.

Lamotrigine: an unusual etiology for aseptic meningitis.

Background Lower gastrointestinal bleeding (LGIB) is a common cause of acute hospitalization. Currently, there is no accepted standard for identifying patients with LGIB in hospital administrative data. The objective of this study was to develop and validate a set of classification algorithms that use hospital administrative data to identify LGIB. Methods Our sample consists of patients admitted between July 1, 2001 and June 30, 2003 (derivation cohort) and July 1, 2003 and June 30, 2005 (validation cohort) to the general medicine inpatient service of the University of Chicago Hospital, a large urban academic medical center. Confirmed cases of LGIB in both cohorts were determined by reviewing the charts of those patients who had at least 1 of 36 principal or secondary International Classification of Diseases, Ninth revision, Clinical Modification (ICD-9-CM) diagnosis codes associated with LGIB. Classification trees were used on the data of the derivation cohort to develop a set of decision rules for identifying patients with LGIB. These rules were then applied to the validation cohort to assess their performance. Results Three classification algorithms were identified and validated: a high specificity rule with 80.1% sensitivity and 95.8% specificity, a rule that balances sensitivity and specificity (87.8% sensitivity, 90.9% specificity), and a high sensitivity rule with 100% sensitivity and 91.0% specificity. Conclusion These classification algorithms can be used in future studies to evaluate resource utilization and assess outcomes associated with LGIB without the use of chart review.