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Vol. 35

Num. 5

May 12

To Promote Improved

Patient Care, Research, and

Education in Primary Care and

General Internal Medicine

InspireInformConnect

CONTENTS

1. Quality Review: Part I . . . . . . . . . . 1

2. Quality Review: Part II . . . . . . . . . 2

3. President’s Column . . . . . . . . . . . . 3

4. Point . . . . . . . . . . . . . . . . . . . . . . . . 4

5. From the Editor . . . . . . . . . . . . . . . 4

6. Counterpoint . . . . . . . . . . . . . . . . . 5

7. Editorial . . . . . . . . . . . . . . . . . . . . . 6

8. New Perspectives . . . . . . . . . . . . . 7

9. Health Policy Corner . . . . . . . . . . . 8

10. Morning Report . . . . . . . . . . . . . . . 9

11. Update . . . . . . . . . . . . . . . . . . . . . 10

12. Sign of the Times . . . . . . . . . . . . . 15

SGIMFORUMThe Society of General Internal Medicine

QUALITY REVIEW: PART I Get with the Guidelines: The Importance of Quality Improvement from a Resident’sPerspectiveAndres Borja, MD

Dr. Borja is a PGY-2 resident in internal medicine at St. Joseph’s Hospital &Medical Center in Phoenix, AZ.

continued on page 13

In a rapidly changing health care system, primary care physicians have tobecome leaders and stay ahead of change. We are expected to see the

same number of patients in less time and with less reimbursement, mak-ing quality measures harder to achieve. With new models of care develop-ing rapidly, it is up to us to improve our service and keep up with thetimes. In this respect, quality improvement projects benefit our practice.

Our patients are complex. Although we do not always have time toaddress all problems in one patient visit, we cannot compromise patientcare due to the pressures of time. It is important to use guidelines andscreening and diagnostic tools in the appropriate setting. Still, guidelineschange rapidly, and we have to adjust our practice accordingly to provideexcellent patient care and improve satisfaction.

Quality problems include underuse, overuse, and misuse of services.Reviewing charts and using statistical analysis to interpret our data willhelp improve our practices. It is important then to keep developing pro-jects in our practices to improve patient care. The question then is: Howdo we develop these projects? The first requirement is to follow our pas-sion—choose projects that you enjoy. Since I have a special interest inpulmonary disease, my project involved the most common pulmonary dis-eases in the primary care setting: chronic obstructive pulmonary disease(COPD) and asthma. Research the latest guidelines, and review yourcharts to evaluate your performance in that specific area. Each of us has aunique approach to addressing clinical problems; once you find your solu-tion, implement it—and don’t forget to evaluate the improvement.

My project included a review of all the patients seen during the lastsix months of 2011 by the residents at the Mercy Care Internal MedicineClinic of St. Joseph’s Hospital & Medical Center. During my review, I

Our Mistake!You may have already realized that in 2012 you received two March issues of SGIM Forum. The editorial staff humbly apologizes for neglecting to change the issue number and date on the April issue. The issue with President’s Column prominently displayed on page 1 is the real April issue. No fooling.

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Medical Quality defines medicalquality as “the degree to whichhealth care systems, services, andsupplies for individuals and popula-tions increase the likelihood for posi-tive health outcomes and areconsistent with current professionalknowledge.” The focus onprocesses and systems is critical toquality improvement (QI) and sug-gests that QI is best conceived ofand taught as a verb (i.e. a process)instead of a noun.

The Accreditation Council forGraduate Medical Education(ACGME) has attempted to integrateQI into postgraduate medical educa-tion through its Practice-BasedLearning and Improvement (PBLI)and Systems-Based Practice (SBP)core competencies—both of whichare quality improvement concepts.Although such concepts can betaught through didactic (e.g. lec-tures, journal clubs) and applied (e.g.morning report, morbidity and mor-tality conferences) methods, theresident-driven QI project remainsthe cornerstone of experiential QIteaching. Many permutations of QIprojects have been used success-fully, but effective projects all sharea fundamental philosophy—systemanalysis and improvement.

Paul Batalden, MD, famouslynoted that “every system is per-fectly designed to achieve exactlythe results it gets”—the so-calledfirst law of health care improve-ment. By extension, if the outcomesachieved are not the outcomes de-sired, the failure likely rests with theprocess. Yet many trainees have lit-tle understanding of the processesat play in their clinical microsystem.Rather than troubleshoot every inef-ficiency, trainees with busy sched-ules and infrequent episodes in theoutpatient clinic develop expertise inthe art of the workaround. A

Many define quality in medicineas practicing to the fullest ex-

tent of current professional knowl-edge, which is best exemplified byfamiliarity with randomized con-trolled trials (RCTs). Yet the RCT as agold standard is a very recent phe-nomenon, and facility with availableRCTs is a poor marker of quality.

The first RCT was published in1948 by the British MedicalJournal—a landmark study titled“Streptomycin Treatment of Pul-monary Tuberculosis.”1 By 1966, approximately 100 RCTs were pub-lished each year.2 The physician of1960 could truly have read everyRCT ever published!

Fast-forward to 1995, whenmore than 10,000 randomized controlled trials were published annually;2 as of March 2012, theCochrane Library lists more than670,000 such publications in its Reg-istry of Controlled Trials.3 The mostbrilliant contemporary physician can-not hope to master such a dauntingdatabase. Does this imply that weare destined to provide deficientcare?

Clearly, there is more to medicalquality than simple knowledge ofthe facts. The American College of

OFFICERS President

Harry P. Selker, MD, MSPH Boston, MAhselker@tuftsmedicalcenter.org (617) 636-5009

President-ElectAnn B. Nattinger, MD, MPH Milwaukee, WIanatting@mcw.edu (414) 805-0518

Immediate Past-PresidentGary E. Rosenthal, MD Iowa City, IA Gary-rosenthal@uiowa.edu (319) 356-4241

TreasurerCarol K. Bates, MD Boston, MAcbates@bidmc.harvard.edu (617) 667-4877

Treasurer-ElectKatrina Armstrong, MD, MSCE Philadelphia, PAkarmstro@mail.med.upenn.edu (215) 898-0957

SecretaryJean S. Kutner, MD, MSPH Denver, COjean.kutner@ucdenver.edu (303) 724-2240

COUNCIL

Clarence H. Braddock III, MD, MPHStanford, CAcbrad@stanford.edu(650) 498-5923

Shobhina G. Chheda, MD, MPHMilwaukee, WIsgc@medicine.wisc.edu(608) 263-2780

Carlos A. Estrada, MD, MSBirmingham, ALcestrada@uab.edu (205) 934-3007

Thomas H. Gallagher, MD Seattle, WAthomasg@uw.edu(206) 616-7158

Nancy L. Keating, MD, MPHBoston, MAkeating@hcp.med.harvard.edu(617) 432-3093

Somnath Saha, MD, MPH Portland, ORsahas@ohsu.edu(503) 220-8262

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

Executive DirectorDavid Karlson, PhD1500 King St., Suite 303Alexandria, VA 22314KarlsonD@sgim.org(800) 822-3060; (202) 887-5150, 887-5405 Fax

Director of Communicationsand Publications

Francine Jetton, MAAlexandria, VAjettonf@sgim.org(202) 887-5150

EX OFFICIO COUNCIL MEMBERS

Chair of the Board of Regional LeadersMichael D. Landry, MD, MS New Orleans, LAmlandry@tulane.edu (504) 988-6128

ACLGIM PresidentRussell S. Phillips, MD Boston, MArphillip@bidmc.harvard.edu (617) 667-4916

Co-Editors, Journal of General Internal MedicineMitchell D. Feldman, MD, MPhil San Francisco, CAmfeldman@medicine.ucsf.edu (415) 476-8587

Richard Kravitz, MD, MSPH Sacramento, CArlkravitz@ucdavis.edu (916) 734-1248

Editor, SGIM ForumPriya Radhakrishnan, MD Phoenix, AZpradhakri@chw.edu (602) 406-7298

Associate Member RepresentativeBradley H. Crotty, MD Boston, MAcrotty@post.harvard.edu (617) 575-9304

QUALITY REVIEW: PART II

The Quality JourneyDaniel G. Tobin, MD, FACP

Dr. Tobin is president of the SGIM New England Region and assistantprofessor of medicine at Yale University School of Medicine.SOCIETY OF GENERAL

INTERNAL MEDICINE

continued on page 11

Almost every year, the head of thehospital system connected with

my medical school articulates thecurrent crisis. He is effective in itsdescription—often some combinationof impending payment cuts, payormix shifts, and/or new competitionfrom a boutique hospital (heart, or-thopedics, cancer, etc.), which soonwill be siphoning off the few caseson which the hospital makes its an-nual operating margin. And he is es-pecially effective in using the crisis toproduce results that improve the effi-ciency of the hospital system (e.g.lesser increases in compensation,lower cost procedure trays, andgreater productivity expectations perunit of support). The crisis of the yearis not wasted, which is one of thereasons this hospital system has apositive operating margin while sev-eral hospitals in the area have closedor merged. I continue to marvel dur-ing each budget season at the effec-tiveness of this leadership strategy.

I have learned some importantlessons from observing this strat-egy. One is about communication.When advocating for change(whether locally or nationally), it iscritical to communicate in relativelysimple and unambiguous terms acompelling need for change (the cri-sis). We in SGIM comprise a Societyfull of thoughtful and criticalthinkers, and I think we are some-times guilty of wanting to explain allthe nuances in such a way that ouraudiences may hear those nuancesmore than the key message. Whileit is a good thing that we understandthe incredible complexity of ourfield, for communication outside our

Society we need to be clear andstay on message.

SGIM members are well awarethat general internal medicine (GIM)is facing a crisis. Shortages of gen-eralist physicians (ambulatory and in-patient) already exist, in GIM as wellas other fields. The venerable NewYork Times journal of medicine saysthat 60 million patients are withoutprimary care doctors,1 and anyonewho has tried to hire GIM hospitalmedicine specialists can attest tothe shortage of inpatient-oriented in-ternists. This shortage is likely toworsen as the changes included inthe Health Care Reform legislationare phased in, thus raising the de-mand for primary and secondarycare—areas that are the bailiwick of GIM.

Numerous articles, most concen-trating on primary care, have beenwritten to explain the lack of suffi-cient physicians entering generalistfields. While many explanations havebeen put forth, in my view they re-duce to two basic problems. The firstis compensation, and the second isthe professional environment associ-ated with generalist careers.

The compensation of generalistspecialists per unit of clinical work istoo far inferior to the compensationfor other specialists to attract gener-alists in the numbers needed. Muchof relative physician compensation isset by the Relative Value Scale Up-date Committee, also called theRUC, a committee consisting mainlyof representatives of professional so-cieties. This committee is dominatedby non-generalist fields, with onlyfive of 29 RUC members from pri-

PRESIDENT’S COLUMN

Let’s Not Waste a CrisisAnn B. Nattinger, MD, MPH

Given the high financial stakes and the fact that the makeup of the RUC favors historical inequities in relative compensation, expecting the compensation situation to self-correct is pure wishful thinking.

continued on page 14

mary care.1 Given the high financialstakes and the fact that the makeupof the RUC favors historical in-equities in relative compensation,expecting the compensation situa-tion to self-correct is pure wishfulthinking. I am not clear whetherphysicians overall are paid too much,as some have concluded. As theeconomist Uwe Reinhardt haspointed out,2 US college graduatesbright enough to enter medicalschool would be able to secureother high-paying jobs if careers inmedicine became less attractive,and if the compensation of all physi-cians were to decline by 20%, totalnational health spending would bereduced by only 2%. What I am sureof is that the inequity in incomes be-tween generalist specialists andmost other specialists has led manytop-notch early-career physicians tochoose more lucrative careers.

I suspect that some general in-ternists who concentrate on inpa-tient medicine are thinking that my

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EDITOR IN CHIEF

Priya Radhakrishnan, MD Priya.Radhakrishnan@DignityHealth.org

MANAGING EDITOR

Christina Slee, MPH tinaslee@me.com

EDITORIAL BOARD

Chayan Chakraborti, MD cchakra@gmail.comMichele Fang, MD michele-fang@uiowa.eduPatty Harris, MD, MS patricia.harris.md@gmail.comFrancine Jetton, MA jettonf@sgim.orgMike Landry, MD, MS mlandry@tulane.eduDenise Millstine, MD Denise.Millstine@DignityHealth.orgDouglas Olson, MD olson.douglas@gmail.comAndrew Schutzbank, MD, MPH aschutzb@bidmc.harvard.eduNeeraj Tayal, MD Neeraj.Tayal@osumc.eduCharmaine Wright, MD smich@mail.med.upenn.eduDouglas Wright, MD, PhD dewright@partners.org

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 those in-terested 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 official po-sition of SGIM. Articles are selected or solicited based on topical interest, clarity of writing, and potential to engage the read-ership. The Editorial staff welcomes suggestions from the reader-ship. Readers may contact the Managing Editor, Editor, or EditorialBoard with comments, ideas, controversies or potential articles. This news magazine is published by Springer. TheSGIM Forum template was created by Phuong Nguyen(ptnnguyen@gmail.com).

SGIM Forum

The decades long debate on therelationship between the pharma-

ceutical industry and physicians con-tinues with renewed interest due tothe Physician Payment Sunshine Act

education (CME) activities should bedeveloped without industry supportand without the participation ofteachers or program planners who

(PPSA). The restrictions have signifi-cantly increased, with the AmericanMedical Association Council on Ethi-cal and Judicial Affairs stating that“when possible” continuing medical

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FROM THE EDITOR

Medical Education: To Pharma or Not?Priya Radhakrishnan, MD

Dr. Radhakrishnan is editor of Forum and can be reached at PRadhakri@dignityhealth.org.

continued on page 5

As physicians, we are trained tocontemplate the risks versus

benefits of almost all encounters. It’ssecond nature; it’s engraved. It’s as ifwe cannot function without debatingthe risks, benefits, and alternatives ofevery situation we encounter.

However, how often do you findyourself pondering the pharmaceuti-cal company-sponsored pizza orpasta you had for lunch? And that itwill, inevitably, influence your prac-tice, affect your credentials, andcomprise your integrity? In residency,our salaries are disproportionate toour debt. We look for as many placesto cut costs as possible, and tradi-tionally, lunch has been one of them.Just keep in mind that there is nosuch thing as a “free lunch.”

How does this work? Accessibilityis the key. Pharmaceutical represen-tatives are notorious for extractingdata collected by the hospital andnetworking with nurses to identifyprescribing practices. For instant net-working, representatives can navigatethrough cafepharma.com, which is awebsite dedicated to pharmaceuticaland medical sales professionals.

Back to that innocent pharmaceu-tical company-sponsored lunch. Ifyou sign your name on their atten-dance document, you are guaranteeda blog on their infamous networkingwebsite, cafepharma.com. Keep in

program coordinator, or vice versa theprogram coordinator can withhold in-formation. Additionally, representa-tives can be excluded geographically;access to the actual conference roomcan be restricted. Furthermore, youcan choose to remain anonymous oroffer to pay for your own lunch. As Istated before, there is no such thingas a “free lunch.”

I believe that the conflict be-tween medical professionals and thepharmaceutical industry will be ever-lasting. When you expose yourself tothe pharmaceutical industry, any giftlarge or small can influence your de-cision making, which can conflictwith the patient care that you pro-vide. Therefore, to refrain from com-promising your integrity, credibility,and your patients’ trust in you, youmust remain “pharm free.”

References1. Corporate Integrity Agreements.

Office of Inspector General, USDepartment of Health andHuman Services.http://oig.hhs.gov/compliance/corporate. Accessed March 26,2012.

2. Weintraub A. New health law willrequire industry to disclosepayments to physicians. KaiserHealth News. Accessed March26, 2012. SGIM

mind that your patients can visit thiswebsite. As an extrapolation, yourpatients are now privy to your affilia-tions and how they may influenceyour prescribing practices. Not onlydo you lose your creditability, butmore importantly you lose your pa-tients’ trust in you.

How are pharmaceutical compa-nies regulated? The Corporate In-tegrity Agreement, also known asthe CIA, protects the integrity of theDepartment of Health and HumanService programs. This is a federalact that sanctions companies that vi-olate marketing rules. The CIA is arestrictive agreement that is imposedwhen misconduct is discovered onbehalf of pharmaceutical companies.1

“Physicians who accept speakingfees and meals from pharmaceuticalcompanies are revealed on theWeb...drawing attention to such fi-nancial benefits.”2 The Physician Pay-ment Sunshine Act requiresmanufacturers and group purchasingorganizations to report all physicianpayments over a cumulative value of$100. This information is also avail-able to your patients on the Web.

How can you limit this access? Inteaching institutions, we can restrictthe access that pharmaceutical com-panies have to our department. Inother words, they can be prohibitedfrom extracting information from the

POINT

“Pharm Free” is the Way to Be (...There is no Such Thing as a “Free Lunch”)Punal Patel, MD; James Gee, MD; and Kevin Olden, MD

Dr. Patel is chief resident, Dr. Gee is a PGY-2, and Dr. Olden is vice chair of internal medicine at St. Joseph’s Hospital& Medical Center in Phoenix, AZ.

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COUNTERPOINT

Let’s Have Lunch! Doctors’ Attitudes are Controlled by Their Minds,not Their StomachsAndres Borja, MD; Mohan Kumar, MD; and Suzanne Plush, DO

Drs. Borja and Kumar are PGY-2 residents and Dr. Plush is a hospitalist at St. Joseph’s Hospital & Medical Center inPhoenix, AZ.

have financial interests in the sub-ject matter.

Should pharma representativesbe allowed to interact with residentsand students? Are the regulationstoo rigid? We reviewed the data onthe relationship between industryand physicians in a recent debate. In-terestingly, the views of our resi-dents reflect the political reality ofour nation, with several taking excep-tion to the role of government intheir activities while others sup-ported the need for regulation.

Like it or not, the proposed legis-lation requires transparency in report-ing any gifts over $100—the data willbe available on a public website. In-terestingly, the “doctor dinners”sans CME credit still fall in thepurview of the proposed legislationand will be reportable.

We have two opposing views re-garding the role of industry in medicaleducation. Weigh in and write to us.

Suggested Readinghttp://www.prescriptionproject.org/

tools/sunshine_docs/files/0001.pdfhttps://www.federalregister.gov/

articles SGIM

FROM THE EDITORcontinued from page 4

In recent years, there has been a lotof controversy around the presence

of pharmaceutical companies in residency training programs and theirimpact on residents’ behaviors andprescribing habits. The dilemma remains present, and the solution isnot simple.

Lunch is the time we have for oureducational conferences; it is noteasy to plan, organize, and schedulethese events, and attendance is im-portant and required by the AmericanCouncil on Graduate Medical Educa-tion (ACGME) during residency. Withincreasing GME budget cuts, mostdepartments are no longer able toprovide food for conferences. How-ever, providing free lunches signifi-cantly increases attendance (OR1.26-1.64)1—not to mention, punctu-ality. We all know our cafeteria hasthe longest lines exactly at the timewe are rushing from rounds to con-ference; if we had lunch provided, wewould be able to pick it up just beforeentering our conference.

We are all well aware of the datathat argue against the free lunch andits potential impact on prescribinghabits and preferences. However, arewe not bombarded by pharmaceuti-cal ads on television that condition usto remember certain medicationswhen treating our patients?

We have intensive curricula in evi-dence-based medicine that help usdevelop our critical-thinking skills dur-ing residency. Having the ability touse these skills in a supervised envi-

ronment is the best test of our abilityto sort the fluff from the data. Shouldhaving a five-minute lecture by phar-maceutical companies, followed by aguided discussion between residentsand attendings, not be a part of oureducational experience? Residency isconsidered a safe environment,where our decisions are backed upor corrected by our faculty. This willensure that we are able to analyzethe relevant clinical data and not beswayed by the armies of pharmareps that we see in practice today.

A big concern is the potential forprescribing bias. What is not consid-ered is the fact that our prescribingpatterns are pre-determined by hospi-tal and clinic formularies. Our pre-scriptions are routinely changed bythe pharmacy based on their costs tothe hospital system. We are alreadybiased by the brand names the hospi-tal buys. Finally, the medication sam-ples ensure that patients who areunable to afford medications can trynew therapies that would otherwisebe out of reach. While the combina-tion of long-acting beta agonist andsteroid is the cornerstone of COPDtherapy, it is not unusual for patientsto have difficulty managing the costsof their treatment. In real life, are wenot more likely to prescribe thosemedications that help our patientswhen they cannot afford them?

In conclusion, we would like tosubmit that the answer is complex;however, we should consider thatresidents will one day interact regu-

larly with pharmaceutical companies.Residency is the time to train, prac-tice, learn, and assimilate the experi-ences that will determine ourpracticing patterns. Like lifelong learn-ing, it is vital that we learn good be-haviors during residency and not shyaway from real life experiences.

Reference1. Fitzgerald J, Wenger N. Didactic

teaching conferences for IMresidents: who attends, and isattendance related to medicalcertifying examination scores? J Acad Med 2003; 8(1):84-9. SGIM

We have intensive curricula in evidence-based

medicine that help us develop our critical-thinking

skills during residency. Having the ability to use these

skills in a supervised environment is the best test of

our ability to sort the fluff from the data.

As I completed my internal medi-cine training in 1999, the Institute

of Medicine (IOM) published To Err IsHuman. The IOM claimed that up to98,000 lives are lost yearly frommedical errors. This landmark docu-ment helped spur the implementa-tion of health information technology(HIT). The assumption has been thatwith computer support, we can im-prove safety and quality. The federalgovernment has accelerated HITadoption further with large financialincentives in its “Meaningful Use”program, which extends into 2014.

The complexity of modern HITsystems and a shortened timeline fordeployment have created the poten-tial for significant errors in design andimplementation. As a result, a signifi-cant risk to patients has been cre-ated by the very systems intended toimprove safety. Errors related to HITare growing, but the scope of theproblem remains difficult to measure.

Recently, the IOM summarizedthe impact of HIT on patient safetyand made recommendations to limitharm. In 2011, it published “HealthIT and Patient Safety: Building SaferSystems for Better Care.” This publi-cation called for a greater effort inensuring that safety is prioritized inthe design, implementation, andmaintenance of HIT systems. Onecommittee member, Richard Cook,MD, even recommended that HITsystems be regulated by the Foodand Drug Administration.

In the coming years, we will seea growing focus on HIT safety. Im-provement efforts will be the task ofmany parties, including IT depart-ments, vendors, and governmentalagencies. The focus will be on usabil-ity, interoperability, and improving theease of implementing and maintain-ing systems.

As physicians we should be re-minded that we have the ability to

templates and preference lists with colleagues.

As important as pre-live trainingis, “post-live” training and educationis more critical to organizational suc-cess. At this point, users have moreinsightful questions and are able tolearn advanced functions. They willalso need continued training as en-hancements are implemented. With“Meaningful Use,” we should expectan aggressive schedule of updates.

One of the greatest challenges totraining remains time. Physicianssimply do not have the luxury ofspending hours in training. They alsocannot travel repeatedly to computertraining labs. They need training thatis delivered to them in a time-effi-cient manner. The information needsto be customized to their needs andshould be presented in a mannerthat allows them to apply what islearned easily.

Tip sheets are commonly used toprovide ongoing training. They areeasy to produce and disseminateover e-mail. Unfortunately, applyinginformation from these documentsrequires a significant effort. Many ofour physicians have fatigued from thebarrage of tip sheets. The value of tipsheets has been lower than hoped.

One-on-one training is resource-intensive, but given the cost of an in-efficient physician, it may be wellworth the investment. Our depart-ment has hired an EMR trainer whois available to provide shoulder-to-shoulder support for physicians. Thisconcierge training has been invalu-able for those who struggle themost. Physician trainers, if available,can teach colleagues to use theEMR very efficiently. They can targetthe highest-value topics and provideexamples that resonate with physi-cian learners.

Short video lessons that demon-

improve the safety of HIT now. Wecan strive to master rather than sim-ply learn the basic operations ofthese systems. With a deeper under-standing of how they function, wecan identify opportunities for im-provement and share them with de-velopers. We bring a uniqueunderstanding of HIT behavior at thepoint of care.

We should redouble our efforts intraining physicians to use electronicmedical records (EMRs). Physiciansspend many hours honing their un-derstanding of pathophysiology andpharmacology. They apprentice andseek certification to perform invasivemedical procedures. The same rigorshould apply to mastering the opera-tions of a modern day EMR.

The rest of this discussion willfocus on lessons learned at our in-stitution as we taught more than1,000 physicians to use the EMR.“Pre-live” training was very impor-tant; however, instructors should un-derstand that learners can absorb alimited amount of information be-fore fatigue sets in. Content shouldprovide a broad introduction to thesoftware interface along with anoverview of the system’s range andscope. This will help learners appre-ciate how the EMR will impact theirworkflows and hopefully impress onthem the importance of future train-ing efforts. Providing access to thesystem immediately after trainingcan allow users to start buildingtemplates and preference lists.These are high yield activities thatcan empower learners to prepare.“Playground environments” can beused to practice, but understandthat very few will have the time to“play.” We found that some earlyadopters spent time building tem-plates and preference lists and alsospent time in the playground. In addition, they often shared their

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EDITORIAL

Health Information Technology: Patient Safety and the Importance of Training and EducationNeeraj H. Tayal, MD, FACP

Dr. Tayal is an assistant professor of medicine at the Wexner Medical Center at The Ohio State University.

continued on page 11

As we see the continued develop-ment of the hospitalist move-

ment in general medicine, more andmore outpatient physicians like my-self have chosen to let inpatientmedicine be done by inpatient physi-cians. I generally visit my patients inthe hospital if I know that they havebeen admitted locally but do not re-ally get involved in the care to anygreat degree. Often, they are admit-ted out of town. Still, at some point,they are considered fit to leave andare returned to my care. As the out-patient gatekeeper, I find the sys-tem generally works well, andhaving inpatient and outpatientphysicians as separate entities hasmany advantages. Still there aresome issues that continue to hinderwhat otherwise could be a very effi-cient and streamlined system.

I work in a relatively closed sys-tem (VA Hospital system) but stillmay not find out until later that mypatient has been admitted. Some-times I find out because I receive reports about tests and their resultswhile my patient is hospitalized, butmost of the time it is a surprise.There does not seem to be any realcoherent system to notify the pri-mary care outpatient physician thathis/her patient has been admitted.Even if the patient is admitted to myhome hospital, I am hardly ever noti-fied. It is very rare that I am notifiedif my patient is admitted to an out-side facility. There are obvious ad-vantages to being notified of mypatient’s admission, such as making

myself when to make the appoint-ment for the patient. If the patientneeds to have a specific issue fol-lowed up but the discharge sum-mary is not done, the patient maycome to me not knowing exactlywhat the issue is. This can result ina wasted visit for both the patientand myself.

Getting records from the hospi-talization is often an additional prob-lem. When the discharge summaryis delayed or the patient arrives inclinic without any information aboutthe hospitalization, I spend timepiecing together what happened orchasing outside records. This alsoresults in a time consuming andoften non-productive visit, especiallyif I did not know that the patientwas hospitalized in the first place.

I also find I am almost never per-sonally contacted by the hospitalistat the time of discharge. Occasion-ally, I may get an e-mail, but that israre. I realize time constraints prob-ably play a big role in this lack ofcommunication, but being able todiscuss the case as it is wrappedup would be very helpful. Thiswould also be more of a handoff,which is a “hot-button issue” forhospitalists in general and wouldlead to much better coordination of care.

Unfortunately, my patients dealwith multiple health care facilitieswith differing policies and proce-dures. Nonetheless, the issues Ihave listed here tend to be recurringthemes. As practitioners of generalmedicine and primary care, we needto continue to evaluate and improvethese issues, especially given thetrend toward fragmentation of carebetween inpatient and outpatientmedicine. There are many advan-tages to this division; we just needto continue working on making itmore efficient and streamlined.

SGIM

sure the hospitalist has accuraterecords and to fill in any gaps orconcerns that he/she might have. Italso helps to facilitate the coordina-tion of care long before discharge.

Another big issue that arises forme is that medications are oftenchanged during the admission.Some medications are stopped alto-gether for one reason or another,and others are added. Patients re-turn to me confused about whatthey should now be taking. Shouldthey continue the inpatient medica-tion or restart ones they were onbefore? Hospitalists who use spe-cific discharge planning with med-ications, especially when it is doneby a pharmacist, tend to be thebest. It is also helpful for the dis-charge instructions to include notjust a list of medications but alsochanges (i.e. “this one was discon-tinued” or “these two wereadded”). It is not always clear fromthe discharge summary why certainchanges were made, and includingthis in the medication summarywould also be very helpful.

Often I am asked where toschedule one of my patients be-cause the patient was told thathe/she needs to see me one week(or other time frame) after hospital-ization. These intervals for the mostpart seem arbitrary. Even if a labneeds to be rechecked or followedin a week, generally the patientdoes not need to be seen. It wouldbe helpful for me to review the dis-charge information and decide for

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NEW PERSPECTIVES

Looking in from the OutsideWilliam I. Iverson, MD

Dr. Iverson is clinical associate professor at the Carver College of Medicine, University of Iowa Hospitals and Clinics.

7

As practitioners of general medicine and primary care,

we need to continue to evaluate and improve these

issues, especially given the trend toward fragmentation

of care between inpatient and outpatient medicine.

Medicare was created in 1966 topay for the care of the nation’s

senior citizens. Congress reluctantlyand temporarily decided Medicarewould pay teaching hospitals forphysician training. As of now, “tem-porarily” has lasted 46 years.

Originally, Medicare paid for “al-lowable costs,” which included thecosts of graduate medical education(GME) programs. However, in 1983when Congress enacted theProspective Payment System (PPS),which pays a fixed amount per hos-pitalization for clinical care based onthe patient’s diagnosis-related group(DRG), it had to decide whether itwould continue having Medicare payfor GME. It chose to continue pay-ing, using a two-part funding mecha-nism for teaching hospitals. DirectGME (DGME) payments help hospi-tals pay the salaries of residents,teaching faculty, and support staff.DGME is the product of three num-bers: a per resident amount thatvaries by hospital, adjusted annuallyfor inflation; the number of residentsin the hospital (capped for each hos-pital at 1997 levels); and the fractionof discharges from the hospital thatare Medicare beneficiaries. The Indi-rect Medical Education (IME) pay-ment is a percentage amount addedon to each DRG payment. The per-centage is calculated via a complexformula (the only US statute contain-ing an exponent!), where the keyfactor is the ratio of interns/resi-

GME funding is financed by theMedicare payroll tax. It is not vulnera-ble to the annual Congressional ap-propriations process. It can bechanged only if Congress changesthe laws authorizing Medicare.

While DGME payments clearlyaddress the costs of training, IMEpayments are intended to addressthe increased severity of illness ofpatients cared for at teaching hospi-tals, compared to those cared for atnon-teaching hospitals, as well as theinefficiency costs resulting from hav-ing trainees. This means that propos-als to redirect the GME fundingstream to training programs insteadof hospitals (as many have proposed)would likely only apply to DGMEmoney. IME money would continueto stay with hospitals.

Historically, training programs thathave trainees in settings outside thehospital lose funding for the timetrainees are there, which discouragescommunity-based training. The Af-fordable Care Act allows hospitals tocount training time spent outside thehospital in GME calculations, butmore work is required to strengthenthese provisions.

SGIM works with other organiza-tions to support GME funding andimprove how funding is allocated.We also advocate for non-MedicareGME funding including Title VII. Ournext education policy article willcover that.

SGIM

dents to beds (IRB ratio). Congressdefines the change in IME percent-age for each 10% change in a hospi-tal’s IRB ratio (IME adjustment).

Of the $9.2 billion Medicare paidfor GME in 2010, $3 billion was forDGME and $6.2 billion for IME. Themoney is paid to hospitals sponsor-ing training programs rather than tothe training programs or other hospi-tals where training occurs. Whileabout 1,100 hospitals receive GMEpayments, 66% goes to the 200 hos-pitals that have the largest numbersof residents. These teaching hospi-tals receive between 15% and 43%IME add-on to their DRG payments.

When Congress created the IMEpayment, it deliberately set the IMEadjustment at 11.6% (for each 10%change in the IRB ratio)—twicewhat economists believed it shouldbe, so as not to risk damaging the fi-nancial stability of teaching hospi-tals. Since 1983, Congress haswhittled the IME adjustment downto 5.5%. This means that a hospitalwith an IRB ratio of 0.6 gets IMEpayments 5.5% higher than onewith a ratio of 0.5. The MedicarePayment Advisory Commission(MedPAC) has argued that this ad-justment is still more than twicewhat is justified by comparing costsat teaching and non-teaching hospi-tals and should be decreased. Thiswould mean reducing IME pay-ments, harming hospitals that relyheavily on this funding stream.

8

HEALTH POLICY CORNER

How Does Medicare Pay for Graduate Medical Education?Mark Liebow, MD, MPH; Jeff Jaeger, MD; and Mark D. Schwartz, MD

Dr. Liebow is assistant professor of medicine at the Mayo Clinic College of Medicine; Dr. Jaeger is associateprofessor of clinical medicine at the University of Pennsylvania School of Medicine; and Dr. Schwartz is associateprofessor of population health and medicine at the New York University School of Medicine in New York, NY.

A62-year-old female is transferredto our hospital from an outside

facility for management of a sub-arachnoid hemorrhage (SAH) diag-nosed by computed tomography(CT) scan of the head. She isafebrile, hemodynamically stablewith intact consciousness, and hasessentially normal blood tests onpresentation. Her past medical history includes depression. She is a physically active home-maker,denies ever smoking, and does not report a family history of cardiovascular disease.

Non-traumatic/spontaneous he-morrhages are frequently seen, usu-ally occurring in the setting of aruptured cerebral aneurysm or arte-riovenous malformation (AVM).About 80% of cases of SAH resultfrom ruptured berry (circle of Willis)saccular aneurysms. Subarachnoidhemorrhage may be seen com-monly in head trauma. The historyand neurologic examination are es-sential in the diagnosis and clinicalstaging (such as the Hunt and Hessstaging system) of SAH. The diag-nosis is confirmed radiologically bycomputed tomography (CT) scanwithout contrast. In the case of ahigh clinical suspicion of SAH, anegative CT scan is followed withlumbar puncture. Non-contrast CTfollowed by CT angiography (CTA)of the brain can rule out SAH withgreater than 99% sensitivity.1

These patients are usually man-aged in the intensive care unit, withcareful attention to blood pressuremanagement. A major focus is toprevent cerebral vasospasm-relatedcomplications. Surgical treatment toprevent re-bleeding consists of clip-ping or endovascular treatment bycoiling of the offending berryaneurysm.

On physical examination, her

known complication of subarach-noid hemorrhage, and several vari-ants of this dysfunction have beendescribed in the literature rangingfrom descriptions such as Takot-subo cardiomyopathy (broken heartsyndrome) to neurogenic stunnedmyocardium.4 The differences be-tween the two entities relate to thevariations noted in echocardio-graphic findings. In the neurogenicstunned myocardium, the cardiacapex is usually spared, and there isbasal hypokinesis; however, inTakotsubo cardiomyopathy (TCM),there is apical akinesis and basalsparing.5

Takotsubo cardiomyopathy is atransient cardiac dysfunction that in-volves left ventricular apical dysfunc-tion resembling acute coronarysyndrome. TCM was first describedin Japan in 1990. Patients often pre-sent with chest pain and may haveST-segment elevation on electrocar-diogram and elevated cardiac en-zyme levels consistent with amyocardial infarction. However,when the patient undergoes cardiacangiography, left ventricular apicalballooning is present, and there isno significant coronary artery ob-struction. On this association, theMayo criteria were developed forthe diagnosis of Takotsubo car-diomyopathy based on available lit-erature.6 They include:

• Transient hypokinesis,dyskinesis, or akinesis of the left ventricular mid-segments,with or without apicalinvolvement (The regional wallmotion abnormalities extendbeyond a single epicardialvascular distribution, and astressful trigger is often, but notalways, present.);

vital signs include a temperature of38° C, heart rate 90 beats/minute,blood pressure of 150/90 mm Hg,and oxygen saturation 99% on roomair. Neurological examination revealsmeningeal signs with no focal neu-rological deficits and intact menta-tion. The examination of all otherorgan systems is normal.

She undergoes emergency cere-bral angiography and coiling of a rup-tured anterior communicating artery(ACOM) aneurysm followed thenext day by elective coiling of an un-ruptured second ACOM aneurysm.Post procedure, the patient is placedon vasopressor support to circum-vent cerebral vasospasm with nor-epinephrine, dobutamine, andvasopressin. An echocardiogram isdone showing normal contractilityand left ventricular ejection fraction.

Ten days later, the patient is se-verely hypotensive and unrespon-sive to vasopressor support. Cardiacenzymes are elevated with no elec-trocardiographic changes noted. Thepatient’s neurological status wors-ens, and she requires intubationwith mechanical ventilation. Anechocardiogram shows severely im-paired left ventricular function withan ejection fraction of 10%, apicalakinesis with ballooning, and basalwall sparing.

Knowledge of the cerebral auto-regulatory mechanism is importantpost SAH and is vital in its manage-ment. In the early 1900s, Cushingdescribed the cardiac effects ofsubarachnoid hemorrhage, including elevated blood pressure and brady-cardia.2 Later with the advent of theEKG, Byer et al. described the STsegment and T wave changes inthe EKG.3 Autopsy studies haveshown varying degrees of myocar-dial necrosis and subendocardial he-morrhage. Cardiac dysfunction is a

9

MORNING REPORT

Status Update: Heart BrokenMohan A. Kumar, MD (presenter), and Priya Radhakrishnan, MD (discussant, in italic)

Morning Report is edited by Michael Landry, MD. Dr. Kumar is a PGY-2 resident in internal medicine, and Dr.Radhakrishnan is the chair of medicine at St. Joseph’s Hospital in Phoenix, AZ.

continued on page 12

Generalist physicians are expectedto stay current on a wide variety

of clinical conditions and in thecourse of a year’s practice will coun-sel patients on hundreds of medicaldecisions. Many clinical decisions inprimary care have a number of ap-propriate choices, and the right deci-sion will depend on the medicalevidence and patients’ preferencesfor good and bad outcomes. Somecommon examples of these kinds ofdecisions include benign prostatic hy-pertrophy treatments and statin usefor primary prevention of cardiovas-cular disease. Doctors and patientsare often advised to use “shared de-cision making” to arrive at the righttreatment plan in these situations.But as a generalist, how does onekeep up with all the evidence behindthese treatment options, communi-cate that information effectively topatients, elicit patients’ preferencesregarding their medical treatments,and jointly agree to a course of treatment—all in the confines of ashort visit? Fortunately, there aremany ways that health informationtechnology (IT) can facilitate shareddecision making.

At Massachusetts General Hospi-tal, we have a Shared Decision Mak-ing Center that supports ourproviders and patients to make bet-ter decisions about medical tests andtreatments. We have focused onthree approaches to facilitate shareddecision making: use of patient deci-sion aids, clinician education andtraining, and measurement of deci-sion quality. Patient decision aids aretools that have been shown to helpdoctors and patients conduct shareddecision making more effectively.Decision aids—available in print,video, and web-based modules—gobeyond simply providing medical in-formation; they present an evidence-

cisions, and reduced the number ofpeople remaining undecided afterusing a decision aid.1

A major challenge in the use ofdecision aids, however, is getting theaids to patients at the “decisionpoint.” Here is an opportunity forhealth IT. Using the EMR and patientregistries to identify patients who arefacing a screening or treatment deci-sion, our delivery of decision aids canbe more precise. For example, awoman turning 40 who may be fac-ing a decision about breast cancerscreening could be “flagged” in theEMR, and her primary care officecould send a decision aid for reviewprior to an upcoming physical. Theprovision of decision aids through theEMR can be patient-directed as well,with a menu of decision aids avail-able via a web portal for patients toaccess directly. Now that ourproviders are comfortable with theaids, they are very interested in ex-ploring these automated and patient-driven options.

Another area of growing interestis the enhancement of specialty re-ferrals by providing a decision aidprior to consultation on preference-sensitive conditions, such as jointreplacement, bariatric surgery, andbreast cancer treatment. Often, theact of making a referral indicatesthat there is a significant decisionthat needs to be made. Many EMRsinclude referral forms that can iden-tify patients appropriate for decisionaids at the time of referral. Imaginea process in your practice that facili-tates the prescription of a decisionaid prior to consultation with an or-thopedist specializing in arthroplasty(who, incidentally, has a three-month waitlist for consultations).You refer two patients with sympto-matic knee osteoarthritis to see this

based view of the advantages anddisadvantages of the options, encour-age patient engagement, and helppatients consider their personal pref-erences and treatment goals. A list-ing of widely available web-baseddecision aids and training tools are in-cluded at the end of this article.

IT has played a core role in sup-porting decision aid use at our hospi-tal. Our providers are able to“prescribe” decision aids to patientsthrough the electronic medicalrecord (EMR). The orders are filledcentrally by staff at our Patient &Family Learning Center, and a note isentered into the EMR documentingthat patient education material wassent. Early acceptance of the pro-grams by doctors required that theyhave control over who received thedecision aids. Not surprisingly, rely-ing solely on clinicians to rememberto order the decision aid has re-sulted in highly variable use—somephysicians are high users and othersrarely prescribe.

Over the past several years, pre-scriptions have increased steadily,and we have received lots of feed-back from clinicians and patients thatthe decision aids are useful in clinicalpractice. Further, we have docu-mented that patients who view deci-sion aids have high knowledgescores and are more certain aboutdecisions related to PSA testing, col-orectal cancer screening, and hip andknee replacement surgery. These re-sults replicate much of what hasbeen found in the Cochrane system-atic review of decision aids. The2011 review included 86 randomizedcontrolled trials of decision aids andfound that the use of decision aidsled to greater knowledge about themedical conditions addressed, re-duced decisional conflict, increasedpatient desire for engagement in de-

10

UPDATE

Resources for Shared Decision MakingLeigh H. Simmons, MD, and Karen R. Sepucha, PhD

Dr. Simmons is a practicing internist and on staff at the John D. Stoeckle Center for Primary Care Innovation atMassachusetts General Hospital. Dr. Sepucha is the director of the Health Decision Sciences Center atMassachusetts General Hospital. They co-direct a demonstration project funded by the Informed Medical DecisionsFoundation focused on implementation of shared decision making in primary care.

continued on page 13

strate optimal EMR workflows havebeen very effective. One simply hasto watch one of the 27 million “Do-It-Yourself” videos on YouTube tounderstand the power of this for-mat. The production quality of ourvideos is amateur at best, but theeducational value remains high.Video screen capture and productionsoftware facilitates easy creation.With proper formatting, physicianscan view videos on desktop or mo-bile devices. Videos should be lessthan five to seven minutes in dura-tion. They should also be com-pressed to less than 7 megabytes tominimize upload time.

Our informal surveys haveshown that 75% of respondentsfound this method of training to be“very helpful.” When asked howvideos compared to other trainingmethods offered, respondentsreplied:

to deploy and has literally hundreds ofintegrated functions. I am confidentthat this marvelous invention called anEMR can improve quality and safety. I am just as confident that physiciansmust dedicate themselves to becom-ing experts in using these systems ifthey expect to improve quality and spatient safety.

References1. Committee on Patient Safety and

Health Information Technology,Board on Health Care Services.Health IT and patient safety:building safer systems for bettercare, 1st ed. Washington, DC:The National Academies Press,2011.

2. Campbell EM, Sittig DF. Types ofunintended consequences relatedto computerized provider orderentry. J Am Med Info Assoc2006; 13:547-56. SGIM

• “The video format is really nice—can view on our own time andreview as needed.”

• “Very nice as no work has to bemissed!”

• “I get much more from the short,directed training modules—andthat they are coming from aphysician using [EMR] in dailypractice—even more helpful.”

• “Better than tip sheets”

It has been 13 years since I com-pleted my residency. I started in apaper system that limited my ability toprovide safe and effective care. I nowoperate in a fully integrated health in-formation system that affords me theability review clinical information,place orders, document findings usingvoice recognition, notify patients elec-tronically of results, and even bill myservices—all with a single softwareapplication. The system cost millions

11

EDITORIALcontinued from page 6

Like the horizon, medical quality issomething we journey toward butcan never truly reach. Systems canalways improve, understanding willalways mature, and humans will al-ways be imperfect creatures. Provid-ing “quality care” is not really adefinable aim; embracing mistakes asopportunities for change, committingto a culture of safety, and having thecourage to journey toward improve-ment is the true goal. As Jean Girau-doux wisely pointed out, “Only themediocre are always at their best.”

References1. Streptomycin treatment of

pulmonary tuberculosis. BMJ1948; 2(4582):769-82.

2. Chassin MR. Is health care readyfor six sigma quality? MilbankQuarterly 1998; 76(4):565-91.

3. Cochrane Library Website.Available at www.thecochranelibrary.com. Accessed March 14,2012. SGIM

QUALITY REVIEW: PART IIcontinued from page 2

workaround is best conceived as theactive neglect of latent errors thatsubsequently fester in a systemburied under layers of managementand undetected or ignored technol-ogy failure.

The problem with workaroundsis that they only work until theydon’t. Failed workarounds are in-evitable and result in medical errors;this is the point where the blamegame gets played. Errors are part ofthe human condition, but systemanalysis can minimize the risk ofpreventable adverse events. Step 1then is a philosophical shift from aculture of blame to a culture ofsafety that emphasizes system re-view and improvement over quickfixes and pointed fingers. Step 2 isdeveloping an awareness of the resources and processes currentlyin place with all of their strengthsand flaws.

A comprehensive system surveyis essential when conducting a QI

project, but the project itself is bestconducted as a focused, easily mea-surable rapid cycle of change. Afterpicking an objective and conductinga system survey, data must be gath-ered (i.e. patient surveys, chart au-dits), synthesized, and analyzed.Only once this has been done can aquality improvement intervention re-ally begin.

The Plan-Do-Study-Act model(PDSA cycle, a.k.a. the DemingWheel or Shewhart Cycle) providesan excellent framework for the nextphase. Planning encompasses defin-ing objectives and developing a prac-tice improvement strategy. “Do” iswhen the plan is implemented anddata are collected on its impact. Dur-ing the “study” phase, the teamcompares actual results against ex-pectations and analyzes where theydiffer. “Act” refers to correcting theprocess to better achieve the objec-tives the next time around. At thispoint, the cycle starts again.

• Absence of obstructive coronarydisease or angiographic evidenceof acute plaque rupture;

• New electrocardiographicabnormalities (either ST-segmentelevation and/or T-waveinversion) or modest elevation incardiac troponin levels; and

• Absence of pheochromocytomaor myocarditis.

After hemodynamic stabilization,the patient undergoes coronary angiography demonstrating the absence of significant coronaryartery disease. After clinical im-provement in hemodynamics, thepatient is placed on an angiotensin-converting enzyme (ACE) inhibitorand beta-blocker. Four weeks later,repeat echocardiography demon-strates improvement in left ventric-ular ejection fraction, representinga spontaneous improvement in hercardiac contractility.

The prognosis for Takotsubo car-diomyopathy is usually favorable, ifappropriate supportive care is pro-vided during the acute phase. It iswidely accepted that neurohor-monal and catecholamine-inducedmyocardial toxicity is most likely tobe the basis of both Takotsubo car-diomyopathy and neurogenicstunned myocardium. Other possi-ble etiologies include multi-vesselcoronary vaso-spasm, impaired car-diac microvascular function, im-paired myocardial fatty acidmetabolism, and even acute coro-nary syndrome with spontaneousreperfusion with associated reperfu-sion injury. The apical portions ofthe left ventricle have the highestconcentration of sympathetic inner-vation found in the heart and mayexplain why excess catecholaminesseem to selectively affect its function.

A significant emotional or physi-cal stressor typically precedes thedevelopment of TCM. Nearly 90%of reported cases involve post-menopausal women. The reversibil-ity of left ventricular dysfunctionwith time and conservative medical

coronary artery disease oncardiac catheterization.

• The characteristicechocardiographic appearanceincludes left ventricular apicalakinesis/hypokinesis (ballooning)with basal sparing.

• Management is supportive, with hemodynamic support inthe acute phase and the use of ACE inhibition and betablockade.

• In most cases, prognosis isexcellent with completereversibility of cardiacdysfunction.

References1. McCormack RF, Hutson A. Can

computed tomographyangiography of the brain replacelumbar puncture in theevaluation of acute-onsetheadache after a negativenoncontrast cranial computedtomography scan? Acad EmergMed 2010; 17(4):444-51.

2. Cushing H. The blood pressurereaction of acute cerebralcompression illustrated by casesof intracranial hemorrhage. Am JMed Sci 1903; 125:1017-4.

3. Byer E, Ashman R, Toth LA.Electrocardiograms with large,upright and long qt-intervals. AmHeart J 1947; 33:796-806.

4. Lee VH, Connolly HM, FulghamJR, Manno EM, Brown RD Jr,Wijdicks EF. Takotsubocardiomyopathy in aneurismalsubarachnoid hemorrhage: anunderappreciated ventriculardysfunction. J Neurosurg 2006;105:264-70.

5. Sealove BA, Tiyagura S, Fuster V. Takotsubo cardiomyopathy. JGen Intern Med 2008; 23:1904-8.

6. Bybee KA, Kara T, Prasad A, etal. Systematic review. Transientleft ventricular apical ballooning:a syndrome that mimics ST-segment elevation myocardialinfarction. Ann Intern Med 2004;141:858-65.

SGIM

management as described in thiscase is characteristic of TCM andreflects the norm that these pa-tients do indeed have an excellentprognosis for full recovery. Mortalityfrom TCM is estimated to be lessthan 3%. Non-mortality-related complications to anticipate includethe following:

• Left heart failure with andwithout pulmonary edema,

• Cardiogenic shock,• Left ventricular outflow

obstruction,• Mitral regurgitation,• Ventricular arrhythmias,• Left ventricular mural

thrombus formation, and• Left ventricular free-wall

rupture.

No medical therapies have beenstudied specifically for TCM; how-ever, it is common practice to pre-scribe ACE inhibitors or angiotensinreceptor blockers at least until leftventricular function is restored.Beta blockers are also indicatedand may be useful in the long term.Other standard outpatient post my-ocardial infarction medications,such as statins, aspirin, and clopi-dogrel, are of unknown benefit.Until the emergence of large ran-domized controlled trials on this in-teresting and relatively novelcondition, it is important for clini-cians to anticipate TCM in high-riskpopulations and recognize and ag-gressively manage it, given its ex-cellent prognosis.

Learning Points• Takotsubo cardiomyopathy often

mimics acute coronarysyndrome in patients (usuallypost-menopausal females) withemotional/physical stressors,which can include medicalproblems such as intracranialcatastrophes.

• TCM often presents with chestpain, ST segment elevation, andelevation in cardiac enzymes inthe absence of demonstrable

12

MORNING REPORTcontinued from page 9

13

2. Qaseem A. Diagnosis andmanagement of stable chronicobstructive pulmonary disease: aclinical practice guideline updatefrom the American College ofPhysicians, American College ofChest Physicians, AmericanThoracic Society, and EuropeanRespiratory Society. Ann InternMed 2011; 155:179-91.

SGIM

QUALITY REVIEW: PART Icontinued from page 1

found 106 patients with a diagnosisof COPD/asthma and 32 with symp-toms compatible with that diagnosis(e.g. dyspnea, cough, and wheezing).I was, however, surprised to find thatof the 138 patients seen during theselected time period, only 11 hadpulmonary function tests (PFT). Ourclinic has a spirometer on site, whichmeans that residents have not beenordering this test. Perhaps residentsare not aware that the guidelinesstate that any smoker with coughand dyspnea should be tested forCOPD and that anybody with a diag-nosis of COPD/asthma requires PFT.There is no consensus on the fre-quency of testing lung function; theAmerican Thoracic Society recom-mends yearly testing, and the Ameri-can College of Physician justrecommends diagnostic PFT. The so-lution? I have proposed an addition toour electronic health record software;

if the diagnosis of COPD/ asthma orhistory of smoking is added to thechart, the software will ask the userif PFT are needed.

As a resident, I think it is of vitalimportance to learn about quality im-provement projects in the practice ofmedicine. We are improving daily andchallenging ourselves to be betterphysicians; why shouldn’t we striveto improve our practices as well? It isalso easier now, in the era of elec-tronic health records, to review ourcharts and make improvementsthrough the software. Consider thatevery one of your patients will bethankful to receive better care, whichshould always be our goal.

References1. ATS/ERS Task Force

Standardization of Lung FunctionTesting. General considerationsfor lung function testing, 2005.

A, Légaré F, Thomson R.Decision aids for people facinghealth treatment or screeningdecisions. Cochrane Database ofSystematic Reviews. Publishedonline October 5, 2011.

Resources for Shared DecisionMaking and Decision Aids• Ottawa Personal Decision Guide

(http://decisionaid.ohri.ca/decguide.html): a general guide that canbe used for any health or socialdecision

• Ottawa Inventory of DecisionAids (http://decisionaid.ohri.ca/AZinvent.php)

• A comprehensive site withmultilingual decision aids(www.thedecisionaidcollection.nl.)

• The Informed Medical DecisionsFoundation (www.informedmedicaldecisions.org)

• The Knowledge and EvaluationUnit at Mayo Clinic (http://shareddecisions.mayoclinic.org)

SGIM

UPDATEcontinued from page 10

surgeon; your first patient views thedecision aid on knee replacementand realizes he is not ready to com-mit to surgery and chooses to focuson weight loss to alleviate kneepain. He cancels his appointment.Your other patient, who has quitesymptomatic arthritis, has viewedthe decision aid and is even moresure about her desire for surgery.She is moved up on the orthope-dist’s waitlist when your first patientcancels. This process benefitseveryone, including the orthopedist,whose schedule will now be bookedwith patients who can benefit mostfrom specialized care.

This system of enhanced spe-cialty referral is a reality for primarycare providers at Group Health inSeattle, WA. Clinicians have the abil-ity to make a referral with or withouta decision aid to certain specialists,including orthopedic surgeons forknee and hip osteoarthritis consulta-tions. David Arterburn, MD, ofGroup Health Research Institute,

notes that “having the decision aidtied to the referral process hashelped us get the programs usedmore consistently. The feedbackfrom the specialists has been posi-tive, as they like having patientscome in better prepared to discusstheir health problems.”

Shared decision making requiresthe synthesis and understanding of asignificant amount of information topromote thoughtful conversationsbetween patients and doctors. IT canbe used to enhance that process—through reliable identification of pa-tients at decision points, workflow tosupport delivery of patient decisionaids, and documentation in the EMR.We should embrace technologicalenhancements as we move to imple-ment decision aids and shared deci-sion making into broad practice.

Reference1. Stacey D, Bennett CL, Barry MJ,

Col NF, Eden KB, Holmes-RovnerM, Llewellyn-Thomas H, Lyddiatt

Each of us has a unique approach

to addressing clinical problems;

once you find your solution,

implement it—and don’t forget to

evaluate the improvement.

14

comments related to compensationdo not relate to them. While hospi-talist compensation often exceedscompensation for ambulatory medi-cine, this is due to a combination ofincreasing demand for the still rela-tively new field and substantial hos-pital cross-subsidies (estimated atmore than $130,000 per physicianannually), not due to adequate pay-ment for clinical services.3 When thesupply of hospitalist physicianscatches up with demand, the hospi-tal executives are likely to take no-tice and reconsider their subsidies.It is not a healthy situation for eitherinpatient- or ambulatory-orientedgeneralists to be so dependent uponcross-subsidies to support clinicalcompensation.

In addition, the professional envi-ronment available to generalists doesnot support the values and vision thattypically lead physicians to take upgeneralist careers—that is, an empha-sis on treating the whole person andattending to the biopsychosocial as-pects of patient care. Instead, mostgeneralist environments emphasizeproductivity based mostly on numberof encounters and based minimallyon the quality of the care provided.Initiatives such as the patient-cen-

icine. One sign of the Society’s movein this direction is the National Com-mission on Physician Payment Re-form, which was spearheaded byHarry Selker during his presidentialyear. The Commission will examinehow physician payment reform canenhance value for the health caresystem while enhancing patient andphysician satisfaction and autonomy.The Commission, chaired by formerSGIM president Steven Schroeder,has been described previously by Dr.Selker in the Forum and is proceed-ing with its work. The Society hasalso secured funds from the Agencyfor Healthcare Research and Qualityto partner with the Society of Teach-ers of Family Medicine and the Am-bulatory Pediatric Association to hosta second national invited conferenceto develop a research agenda to fur-ther inform the adoption of thePCMH model of care delivery.

In addition to these initiatives, Ihave asked our SGIM committeeseach to consider what more we cando to communicate the challengesfaced by our field and to develop andarticulate potential solutions. There isa wide national consensus that ourhealth care delivery system is in cri-sis and requires re-design, eventhough there is disagreement aboutthe solutions. We need to articulatethe crisis as it pertains to GIM andwork among ourselves and with oth-ers to develop solutions. This is areal crisis, and we need to be surewe do not waste it!

References1. Chen PW. How one small group

sets doctors’ pay. New YorkTimes, September 22, 2011.

2. Reinhardt UW. Letters to theEditor: What doctors make, andwhy. New York Times, August 5,2007.

3. Quinn R. How high can yoursupport payments go? TheHospitalist 2011; 7:36-8.

4. Friedberg MW. The potential ofthe medical home on jobsatisfaction in primary care. ArchIntern Med 2012; 172:31-2.

SGIM

tered medical home (PCMH) modelare structured to shift the focus toquality care outcomes and may im-prove physician satisfaction.4 How-ever, the fact is that most generalistsstill work in environments thatstrongly tie compensation to volume.Quality (or value) of the care providedaccounts for a very small percentageof the compensation for most gener-alist physicians, even those workingin PCMH environments.

Traditionally SGIM as an organiza-tion has focused primarily on educa-tion and research issues related toGIM, and we will continue to do so.We have traditionally partnered withother like-minded organizations to ac-complish changes in health policy re-lating to clinical issues andreimbursement, and we will continueto do this as well. However, at itslast retreat, the SGIM Council feltthat the organization needs to in-crease its focus toward articulatingthe crisis that exists for our fieldmore generally, not solely limited tothe education and research aspects.Within the internal medicine umbrellaof organizations, we have an obliga-tion to be strong advocates for ourfield, as we are the group that fo-cuses solely on general internal med-

PRESIDENT’S COLUMNcontinued from page 3

POSITION IN DIVISION OF GENERAL INTERNAL MEDICINEThe Division of General Internal Medicine & Health Services Research invites applications for faculty positions at the Instructor or Assistant Professor level (MD or PhD). Successful applicants will have conducted outstanding,independent scholarly work in health services, epidemiology,or a social science related to health or health care. They willhave the potential to obtain peer-reviewed funding and serveas PI on multidisciplinary research teams. For physicians,research training via fellowship or Master’s program isdesirable. The position includes teaching research skills to fellows. Physicians will also care for patients as well asteach and supervise clinical trainees. The Division has ongoing collaborations with Schools of Public Health, PublicPolicy, and RAND. Send CV, bibliography, and names of three references to: dzingmond@mednet.ucla.edu.

UCLA is an Affirmative Action/Equal Opportunity Employer.

There are some things on whichmost all physicians can agree:

Smoking, excessive alcohol con-sumption, and excessive eating canall damage a patient’s health. In-deed, all of these are modifiablerisk factors for some of the mostcommon diseases we see in gen-eral medicine, including coronaryartery disease, asthma and COPD,obesity, low back pain, and sub-stance misuse and abuse. Mostphysicians would agree that tech-nology—though it improves patientcare—can often be irritating. Forresidents, it is the concept of“hammer paging,” receiving pageafter page. For those further alongin medicine, it shows up as endlesse-mails—either to you or as a “cc”or “bcc”—that can make a long dayseem longer.

Do you agree with the abovestatements? Have you alreadythought to yourself, “Yep, that’s alltrue. So what is the point of this ar-ticle?” The point is this: Those areideas and opinions that doctors hadabout their patients and their workin October 1970. (Clarification: Theymentioned telephones as a frustra-tion, and I changed it to e-mail).The October 2, 1970, issue of Lifemagazine, which featured GeorgeMitchell’s wife Martha on thecover, included a five-page article titled “What Doctors Think of TheirPatients.” I found it on a recent tripto the Berkshires in Western,Massachusetts.

Evidently, a convenience sampleof “500 urban, suburban, and ruralphysicians, all of them general prac-titioners” was asked to participate ina survey about “the follies andweaknesses of their patients.” Eachrespondent was asked to “take aprofessional look” at him or herself.

So what did the survey show?Some of the more notable results

tice what we preach? These ques-tions might all be best answered onan individual basis. And an immedi-ate answer may not be obvious.

What is clear, though, is thattechnology has certainly changed thepractice of medicine. Countless arti-cles lament how advances in tech-nology have replaced the physicalexam. Technology and the use ofiPads have been shown to makephysicians more efficient. And theuse of the Internet has improved out-comes in studies on conditions suchas obesity and diabetes.

In the current era of online doc-tor and hospital ratings, patient-centered health care, pay for perfor-mance, quality indicators, and im-proved patient access to labs andeven physician progress notes,there is impressive critique of physi-cians in everything we do. The newtrend is not even to call those forwhom we care “patients” but rather“health care consumers.” Be it onthe Internet, in a journal, in thenewspaper, or on the evening news,almost everything we do is beingexamined. Well known question-naires such as Picker and HospitalConsumer Assessment of Health-care Providers and Systems (HC-AHPS) ask patients about theirsubjective experiences, national or-ganizations create quality metrics tomeasure our worth as clinicians, andstudy after study shows us howgood we are at educating patientsand making them feel like we listento them.

And all of this is for the good. Itmakes medicine a more transparent,evidence-based, and humble profes-sion. But it leaves me with a linger-ing question: Has patient behaviorand physician opinion changed allthat much over the past fourdecades, or are we just better atquantifying it? SGIM

that have changed little—if at all—in42 years are listed below:

• 56% of physicians agreed that“doctors have to jam so manypatients in, they don’t giveanyone enough attention.” The15-minute visit continues to be asore point for patients andgeneralists alike.

• “Patients expect things of us thatare not possible; they think wecan work forever like machineswithout rest; a doctor is simply aperson, not a god.” Is it a wonderthat more and more residencygraduates who pursue generalmedicine choose hospitalist shiftwork rather than primary care?

• “Their views on how patientsharm themselves most can besummed up in one word:overindulgence.” Today, 33% ofour population is obese.

• 90% of doctors felt most of theirmiddle-aged patients wouldbenefit from regular exercise.21% of those same physiciansdid not exercise themselves.How many physicians wouldtoday state that their patientsshould exercise? How manymeet the current CDCrecommendation of 150 minutesof exercise a week?

• Eight stereotypical patients andfrequent psychosomaticcomplaints that often resulted intheir symptoms were presented.Categories ranged from “thewhite collar worker” and“working women” to “divorcedpeople” and “college age andunder 30.”

So, what do we as generalistphysicians think of their patientstoday in 2012? What types of pa-tients would we classify into groupsof “typical patients”? Do we all prac-

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SIGN OF THE TIMES

The More Things Change, the More They Stay the SameDouglas P. Olson, MD

Dr. Olson is a member of the Forum editorial board and can be reached at OlsonD@chc1.com.

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Society of General Internal Medicine1500 King Street Suite 303Alexandria, VA 22314202-887-5150 (tel)202-887-5405 (fax)www.sgim.org

SGIMFORUM

The ISSN for SGIM Forum is: Print-ISSN 1940-2899 and eISSN 1940-2902.

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