Illicit drug use, and the associated health problems, is a frequent issue encountered by medical providers. Because of its salience as a piece of health care information, drug use history is often included in patient charts and presentations by house staff

Hospitalists provide a significant amount of direct clinical care in both academic and community hospitals. Peer feedback is a potentially underutilized and low resource method for improving clinical performance, which lends itself well to the frequent patient care handoffs that occur in the practice of hospital medicine. We review current literature on peer feedback to provide an overview of this performance improvement tool, briefly describe its incorporation into multi-source clinical performance appraisals across disciplines, highlight how peer feedback is currently used in hospital medicine, and present practical steps for hospital medicine programs to implement peer feedback to foster clinical excellence among their clinicians.

Background

An important component of internal medicine residency is clinical immersion in core rotations to expose first-year residents to common diagnoses.

Objective

Quantify intern experience with common diagnoses through clinical documentation in an electronic health record.

Methods

We analyzed all clinical notes written by postgraduate year (PGY) 1, PGY-2, and PGY-3 residents on medicine service at an academic medical center July 1, 2012, through June 30, 2014. We quantified the number of notes written by PGY-1s at 1 of 3 hospitals where they rotate, by the number of notes written about patients with a specific principal billing diagnosis, which we defined as diagnosis-days. We used the International Classification of Diseases 9 (ICD-9) and the Clinical Classification Software (CCS) to group the diagnoses.

Results

We analyzed 53 066 clinical notes covering 10 022 hospitalizations with 1436 different ICD-9 diagnoses spanning 217 CCS diagnostic categories. The 10 most common ICD-9 diagnoses accounted for 23% of diagnosis-days, while the 10 most common CCS groupings accounted for more than 40% of the diagnosis-days. Of 122 PGY-1s, 107 (88%) spent at least 2 months on the service, and 3% were exposed to all of the top 10 ICD-9 diagnoses, while 31% had experience with fewer than 5 of the top 10 diagnoses. In addition, 17% of PGY-1s saw all top 10 CCS diagnoses, and 5% had exposure to fewer than 5 CCS diagnoses.

Conclusions

Automated detection of clinical experience may help programs review inpatient clinical experiences of PGY-1s.

Giant cell myositis (GCM) is a rare inflammatory myopathy associated with myasthenia gravis and thymoma. Here, we report on a woman in her late 50s with a history of myasthenia gravis, systemic lupus erythematosus and stage IV thymoma with pleural metastases, who presented with proximal weakness, neuromuscular respiratory failure and hypercalcaemia. She was diagnosed with GCM via muscle biopsy and screened for myocarditis but showed no evidence of myocardial involvement. Her hypercalcaemia was consistent with a granulomatous process, likely driven by her GCM. Her strength gradually improved, and her hypercalcaemia did not recur after treatment with high dose steroids, intravenous immune globulin and plasma exchange. Her course was complicated by several opportunistic infections in the setting of her immunosuppression. Despite the high morbidity associated with GCM, she demonstrated clinical improvement after initiating immunosuppressive therapy and continues to be managed in the outpatient setting.

Background

Seriously ill patients frequently receive care in hospitals, and palliative care is a core competency for hospitalists. We aimed to summarize and critique recent research that has the potential to impact the clinical practice of palliative care in the hospital.

Methods

We reviewed articles published between January 2012 and May 2013, identified through a hand-search of leading journals and PubMed. The authors collectively selected 9 articles based on their scientific rigor and relevance to hospital practice. We review their findings, strengths, and limitations and make recommendations for practice.

Results

Key findings include: indwelling pleural catheters and talc pleurodesis provide similar relief of dyspnea in patients with malignant pleural effusions; oxygen many not be needed to prevent dyspnea in many dying patients; docusate may not be needed in addition to sennosides to treat opioid-induced constipation; atropine is no more effective than placebo in treating respiratory rattles in dying patients; many older adult survivors of in-hospital cardiopulmonary resuscitation (CPR) are alive up to 1 year after discharge; observing CPR may decrease family post-traumatic stress; surrogates of intensive care unit patients often interpret prognostic information optimistically; many patients with metastatic cancer feel that chemotherapy may cure their disease; viewing a goals-of-care video may decrease preference for CPR in patients being admitted to skilled nursing facilities.

Conclusions

Recent research provides important insights into the effectiveness of medications and interventions for symptom management, outcomes of CPR for patients and families, and Journal of Hospital Medicine 2013;8:715-720. © 2013 Society of Hospital Medicine.

Background

Academic hospitalists engage in many non-clinical domains. Success in these domains requires support, mentorship, protected time, and networks. To address these non-clinical competencies, faculty development programs have been implemented. We aim to describe the demographics, job characteristics, satisfiers, and barriers to success of early-career academic hospitalists who attended the Academic Hospitalist Academic (AHA), a professional development conference from 2009 to 2019.

Methods

Survey responses from attendees were evaluated; statistical analyses and linear regression were performed for numerical responses and qualitative coding was performed for textual responses.

Results

A total of 965 hospitalists attended the AHA from 2009 to 2019. Of those, 812 (84%) completed the survey. The mean age of participants was 34 years and the mean time in hospitalist practice was 3.2 years. Most hospitalists were satisfied with their job, and teaching and clinical care were identified as the best parts of the job. The proportion of female hospitalists increased from 42.2% in 2009 to 60% in 2019 (p = 0.001). No other demographics or job characteristics significantly changed over the years. Lack of time and confidence in individual skills were the most common barriers identified in both bedside teaching and providing feedback, and providing constructive feedback was an additional challenge identified in giving feedback.

Conclusions

Though early-career hospitalists reported high levels of job satisfaction driven by teaching and clinical care, barriers to success include time constraints and confidence. Awareness of these factors of satisfaction and barriers to success can help shape faculty development curricula for early-career hospitalists.

Problem definition

Performance feedback, in which clinicians are given data on select metrics, is widely used in the context of quality improvement. However, there is a lack of practical guidance describing the process of developing performance feedback systems.

Initial approach

This study took place at the University of California, San Francisco (UCSF) with hospitalist physicians. Participatory design methodology was used to develop a performance dashboard and feedback system. Twenty hospitalist physicians participated in a series of six design sessions and two surveys. Each design session and survey systematically addressed key components of the feedback system, including design, metric selection, data delivery, and incentives. The Capability Opportunity Motivation and Behavior (COM-B) model was then used to identify behavior change interventions to facilitate engagement with the dashboard during a pilot implementation.

Key insights, lessons learned

In regard to performance improvement, physicians preferred collaboration over competition and internal motivation over external incentives. Physicians preferred that the dashboard be used as a tool to aid in clinical practice improvement and not punitively by leadership. Metrics that were clinical or patient-centered were perceived as more meaningful and more likely to motivate behavior change.

Next steps

The performance dashboard has been introduced to the entire hospitalist group, and evaluation of implementation continues by monitoring engagement and physician attitudes. This will be followed by targeted feedback interventions to attempt to improve performance.

Physicians increasingly investigate, work, and teach to improve the quality of care and safety of care delivery. The Society of General Internal Medicine Academic Hospitalist Task Force sought to develop a practical tool, the quality portfolio, to systematically document quality and safety achievements. The quality portfolio was vetted with internal and external stakeholders including national leaders in academic medicine. The portfolio was refined for implementation to include an outlined framework, detailed instructions for use and an example to guide users. The portfolio has eight categories including: (1) a faculty narrative, (2) leadership and administrative activities, (3) project activities, (4) education and curricula, (5) research and scholarship, (6) honors, awards, and recognition, (7) training and certification, and (8) an appendix. The authors offer this comprehensive, yet practical tool as a method to document quality and safety activities. It is relevant for physicians across disciplines and institutions and may be useful as a standalone document or as an adjunct to traditional promotion documents. As the Next Accreditation System is implemented, academic medical centers will require faculty who can teach and implement the systems-based practice requirements. The quality portfolio is a method to document quality improvement and safety activities.