Jeffrey J. Glasheen

Career Satisfaction and Burnout in Academic Hospital Medicine

T he number of hospitalists in academic medical centers has grown rapidly, producing a field with few senior members, potentially impeding the academic success and career sustainability of academic hospitalists, not to mention contributing to burnout. However, little is known about career promotion, job satisfaction, stress, and rates of burnout in academic hospital medicine or how these factors affect scholarly success and productivity.

Fulfilling the Promise of Hospital Medicine: Tailoring Internal Medicine Training to Address Hospitalists’ Needs

Categorical internal medicine (IM) residency training has historically effectively prepared graduates to manage the medical needs of acutely ill adults. The development of the field of hospital medicine, however, has resulted in hospitalists filling clinical niches that have been traditionally ignored or underemphasized in categorical IM training. Furthermore, hospitalists are increasingly leading inpatient safety, quality and efficiency initiatives that require understanding of hospital systems, multidisciplinary care and inpatient quality assessment and performance improvement. Taken in this context, many graduating IM residents are under-prepared to practice as effective hospitalists. In this paper, we outline the rationale for targeted training in hospital medicine and discuss the content and methods for delivering this training.

The Quality and Safety Educators Academy Fulfilling an Unmet Need for Faculty Development

Educating physician trainees in the principles of quality improvement (QI) and patient safety (PS) is a national imperative. Few faculty are trained in these disciplines, and few teaching institutions have the resources and infrastructure to develop faculty as instructors of these skills. The authors designed a 3-day, in-person academy to provide medical educators with the knowledge and tools to integrate QI and PS concepts into their training programs. The curriculum provided instruction in quality and safety, curriculum development and assessment, change management, and professional development while fostering peer networking, mentorship, and professional development. This article describes the characteristics, experiences, and needs of a cross-sectional group of faculty interested in acquiring skills to help them succeed as quality and safety educators. It also describes the guiding principles, curriculum blueprint, program evaluation, and lessons learned from this experience which could be applied to future faculty development programs in quality and safety education.

Hospitalist Educators: Future of Inpatient Internal Medicine Training

Academic hospitalists have grown in number and influence over the past decade. This has fueled concerns about the effect of hospitalists on resident and student education. While the bulk of the literature favors the hospitalist teaching model to a more traditional model concerns remain that hospitalists may negatively impact housestaff autonomy and reduce exposure to subspeciality physicians. This paper will review the literature exploring the effect of the hospitalist teaching model on resident and student education.

Warfarin Therapy Does Not Increase Risk of Symptomatic Intracerebral Hemorrhage in Eligible Patients After Intravenous Thrombolysis

P rabhakaran and colleagues 1 reported that warfarintreated patients with an international normalized ratio (INR) of 1.7 or less had a markedly increased risk of symptomatic intracerebral hemorrhage (SICH) after treatment with intravenous tissue plasminogen activator (IV tPA) for ischemic stroke at a single institution. We examined this issue by analyzing data from the Colorado Stroke Alliance registry, a shared database of 35 Colorado hospitals. Of the 6614 ischemic strokes in the database with complete records, 580 (8.7%) had received IV tPA. Warfarin therapy in patients with an INR of 1.7 or less was reported in 26 of the 580 patients (4.4%), of whom 18 (3.1%) were receiving warfarin alone and 8 (1.4%) were receiving warfarin and an antiplatelet drug. None of the warfarin-treated patients had an SICH, while the overall SICH rate after tPA was 4.8%. There was no statistically significant difference in the rates of SICH between patients who were taking warfarin and those not receiving anticoagulant or antiplatelet therapy (P=.63). As expected, of the 273 patients with INR recorded at admission, the average INR was significantly higher for patients who were taking warfarin than those who were not receiving anticoagulant therapy (1.26 vs 1.03; P .001). Our findings are consistent with the guidelines for IV tPA use in ischemic stroke, which consider patients who are receiving warfarin with an INR of 1.7 or less to be candidates for therapy. The warfarin-treated cohort in Prabhakaran and colleagues’ article was significantly older and had a higher percentage of cardioembolic strokes than the group that was not receiving warfarin. It is known that risk of intracerebral and other major hemorrhage increases with these two factors regardless of whether a patient is receiving warfarin therapy. Thus, the increased incidence of SICH may be explained by patient factors other than warfarin therapy. Furthermore, the overall number of patients in the warfarin group was small, making it susceptible to type I error. In conclusion, we were unable to reproduce the findings of Prabhakaran and colleagues. In fact, we did not observe any SICH in our cohort of warfarin-treated patients with an INR of 1.7 or less. Further research is warranted, but at this time, we would not recommend denying IV tPA to warfarin-treated patients with an INR of 1.7 or less who would otherwise be candidates for this therapy.

Risk Stratification tools for Transient Ischemic Attack: Which patients require hospital admission?

Stroke and transient ischemic attack (TIA) arise from identical etiologies and many fatal or disabling strokes are preceded by a TIA. Ten percent of patients presenting with a TIA will suffer a stroke within 3 months with half occurring in the first 48 hours. Still, many patients with a TIA do not receive timely evaluation or therapy. Hospitalization offers the opportunity for rapid evaluation and secondary prevention, reduced time to thrombolysis for early second strokes, and can be cost effective for high risk patients. Stratification tools are now available which allow individualized assessment of risk for early second strokes based on patient characteristics on presentation. The use of scoring systems such as the ABCD(2) score to predict risk of stroke after TIA are useful in making an evidence-based judgment regarding need for hospitalization. High-risk patients have an 8.1% risk for stroke in the 48 hours after a TIA and warrant hospital admission. Intermediate-risk patients have a 4.1% risk of early second stroke and may be considered for admission, observation, or expedited clinic evaluation. Low-risk patients have a 2-day stroke risk of only 1% and are likely appropriate for prompt outpatient evaluation. TIA is a medical emergency, similar to unstable angina, and high risk patients should receive treatment and prevention measures instituted with comparable urgency.

BOOST: Evidence needing a lift

Division of Hospital Medicine, University of California San Francisco School of Medicine, San Francisco, California; Division of Hospital Medicine, University of Colorado School of Medicine, Denver, Colorado; Division of Hospital Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Division of Hospital Medicine, Northwestern University School of Medicine, Chicago, Illinois; Division of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.

Achieving hospital medicine's promise through internal medicine residency redesign

The promise of the hospital medicine movement is that the hospitalist model of care will provide better outcomes than the system it replaced. This means improving the quality and processes of care, reducing inefficiencies and lowering costs. Despite some documented improvements in these areas hospitalists have yet to achieve their pinnacle. These shortfalls likely result from training providers in residencies that have yet to evolve to address the specific needs of hospitalists. While most internal medicine residency training programs stress inpatient care they underemphasize key components of a successful hospitalist career. This paper overviews the state of the hospitalist movement, the current educational training deficiencies and the methods to deliver hospitalist-focused training.

Understanding predictors of prolonged hospitalizations among general medicine patients: A guide and preliminary analysis

Targeting patients with prolonged hospitalizations may represent an effective strategy for reducing average hospital length of stay (LOS). We sought to characterize predictors of prolonged hospitalizations among general medicine patients to guide future improvement efforts. We conducted a retrospective cohort study using administrative data of general medicine patients discharged from inpatient status from our academic medical center between 2012 and 2014. Multivariable logistic regression was performed to assess the association between sociodemographic and clinical variables with prolonged LOS, defined as >21 days. Of 18,363 discharges, 416 (2.3%) demonstrated prolonged LOS. Prolonged hospitalizations accounted for 18.6% of total inpatient days and contributed 0.8 days to an average LOS of 4.8 days during the study period. Prolonged hospitalizations were associated with younger age (odds ratio [OR]: 0.80 per 10-year increase in age, 95% confidence interval [CI]: 0.73-0.87) and Medicaid insurance (OR: 1.99, 95% CI: 1.29-3.05, REF = Medicare). Compared to patients without prolonged LOS, prolonged LOS patients were more likely to have methicillin-resistant Staphylococcus aureus septicemia (OR: 8.83, 95% CI: 1.72-45.36); require a palliative care consult (OR: 4.63, 95% CI: 2.86-7.49), ICU stay (OR: 6.66, 95% CI: 5.22-8.50), or surgery (OR: 5.04, 95% CI: 3.90-6.52); and be discharged to a post-acute-care facility (OR: 10.37, 95% CI: 6.92-15.56). Prolonged hospitalizations in a small proportion of patients were an important contributor to overall LOS and particularly affected Medicaid enrollees with complex hospital stays who were not discharged home. Further studies are needed to determine the reasons for discharge delays in this population.

USE OF MEDICATIONS FOR INSOMNIA IN THE HOSPITALIZED GERIATRIC POPULATION

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the personal and financial checklist provided by the authors and has determined that none of the authors have any conflicts related to this letter. Dr. Teramoto was supported by a research grant from Mitsui Life Social Welfare Foundation Japan fund and by research grant from Mitsukoshi Health and Welfare Foundation in Japan. Author Contributions: Shinji Teramoto: study concept and design. Yoshinosuke Fukuchi, Hidetada Sasaki, Koichi Sato, Kiyoihsa Sekizawa, Takeshi Matsuse: acquisition of subjects and/or data, analysis. Hidetada Sasaki and Kiyoihsa Sekizawa: interpretation of data. Shinji Teramoto: preparation of manuscript. Sponsor’s Role: Pfizer Japan Inc. supported the data collection and analysis. The sponsor had no role in the design, methods, recruitment, or preparation of this letter. REFERENCES