Welcome to our fourth annual Top Hospitalists issue. Our calls for nominations—sent out last spring and summer—asked for hospitalists who are making significant contributions to the field, whether through innovation, clinical skills, patient safety, research, community involvement, improved work flow, teamwork, leadership or quality improvement. Readers graciously responded to the charge: We heard from peers and mentors, supervisors and administrators. The quantity and quality of candidates spoke to the inspiring work being done in U.S. hospital medicine, making the decision to pick only 10 a tough but rewarding task.
ACP Hospitalist's editorial board members reviewed the nominations and selected the Top Hospitalists, who are profiled on the following pages. These physicians are leaders and teachers, innovators and mentors, researchers and pioneers. Some have distinguished themselves by helping younger physicians get ahead, or helping reduce health disparities in their communities. Others are making great strides in patient safety, education and care transitions. All have contributed greatly to the field of hospital medicine. We're excited to recognize the work of these exceptional individuals. We hope you enjoy reading about them—and look forward to receiving your nominations for next year's honorees.
(ACP Hospitalist's Top Hospitalist competition is not considered part of the ACP National Awards Program.)
Collaborative leadership fosters program growth in Houston
Jasmin M. Baleva, MD
Medical school: University of Philippines
Residency: East Carolina University; University Health System's Pitt County Memorial Hospital
Current title: Hospitalist practice group leader, Memorial Hermann Memorial City Medical Center, Houston Region, IPC The Hospitalist Company
Growing up in the Philippines with a surgeon father and a mother who was an anesthesiologist, Jasmin M. Baleva, MD, didn't have to look far for professional role models. Her father began taking her on rounds at the hospital at age 7, and by age 9 she had started observing her parents in the operating room. Still, she wasn't always convinced she was cut out to be a doctor.
“I went through medical school thinking I was being forced into medicine, but that changed during residency, after I went into a med-peds program and passed all those board exams,” said Dr. Baleva, who now heads up IPC The Hospitalist Company's Houston practice group. “I finally figured I was meant to be a doctor and I embraced it.”
From that moment on, it was full speed ahead for Dr. Baleva. After joining IPC in 2001, she not only started Houston's first med-peds practice group, which now has ten hospitalists, she was also involved in starting hospitalist practices at a long-term acute care hospital (LTACH), and at Methodist Hospital Willowbrook. Her hospitalist group currently covers two short-term acute hospitals, two LTACHs, one children's LTACH, nine skilled nursing facilities, two assisted living facilities, one hospice inpatient unit, and one Alzheimer's facility.
IPC's growth in the region is largely due to Dr. Baleva's collaborative leadership style, said Fred Grates, her colleague and executive director of IPC's Houston region.
“Dr. Baleva communicates her vision to the partners, shares information with them and involves them in decision making,” said Mr. Grates. “She has created a culture where everyone feels safe to express their views and opinions, and empowers them to pursue their interests.”
Dr. Baleva initiated an annual goal-setting meeting where her practice partners share their individual career and personal goals. She adjusts work hours so hospitalists can work anywhere from half- to full-time schedules.
“Some of the doctors want to work hard and make more money; others want more work-life balance for families or to travel—I knew those things affected people's perception of how much they worked,” she said. “The meetings help keep the team invested with no ill feelings toward one another because they understand what everyone's goals are.”
Dr. Baleva's meetings are similarly democratic. She brings any new ideas or proposals to the group for discussion and lets the majority rule, even when she doesn't necessarily agree with the potential outcome. Even if a decision turns out badly, the team “needs to go through the experience to feel that they have ownership of our endeavors,” she said.
Dr. Baleva's leadership has also been instrumental in forging partnerships with skilled nursing facilities (SNFs) and LTACHs that are now using IPC's hospitalist services. In 2008, she initiated the first meeting with Memorial Hermann Memorial City hospital nurse managers, case managers, and local nursing facility administrators and admissions staff to exchange information about how to ensure safe transitions after discharge.
The group has continued to meet annually to share ideas. Dr. Baleva's group recently started working with an independent group of nurse practitioners in the long-term care facilities and some of her hospitalists are now based in those facilities.
“The hospital plus the SNF and LTACH facilities are all a continuum until the patient can go home,” said Dr. Baleva. “Nowadays the expectation is to get people out of the hospital in two or three days, but that will work only for about 25 to 30% of patients. A lot of older patients are too weak or sick to go home and we have to transition them to long-term care to continue their recovery.”
Some of the hospitalists in Dr. Baleva's group work in SNFs to help with the logistical details involved with ensuring safe transitions. For example, they help get patients to and from the hospital for transfusions or outpatient procedures without unnecessarily readmitting them. Dr. Baleva has personally provided nurse education at SNFs and serves on the quality assurance and utilization review committee at an LTACH in West Houston.
“Providing inpatient care at both the acute and post-acute facility level has improved continuity of care, as evidenced by reduction in the 30-day readmission rate to the hospital,” said Mr. Grates. “Dr. Baleva understands that the growth of her group's practice depends on their success at supporting the goals and needs of the hospitals and sub-acute facilities that they serve.”
Innovative simulation training helps residents master procedures
Jeffrey H. Barsuk, MD
Medical school: Northwestern University Feinberg School of Medicine
Residency: Northwestern University, McGaw Medical Center, Northwestern Memorial Hospital
Title: Associate professor of medicine, Northwestern University Feinberg School of Medicine, Chicago
As a medical student at Northwestern University, Jeffrey H. Barsuk, MD, loved the procedural side of medicine. But as a teacher, he became concerned about emerging evidence that traditional bedside teaching methods were falling short in preparing residents to perform basic procedures, such as central line insertion or thoracentesis. He set out to change the system with the help of his colleagues.
“The traditional model of ‘see one, do one, teach one’ just wasn't working,” said Dr. Barsuk, who serves as key clinical faculty for Northwestern's residency program. “Even when residents said they were comfortable with a procedure, they didn't do very well when tested on a simulator.”
Dr. Barsuk helped develop an innovative program to help residents master procedural skills through simulation training. The theory was that residents who first practiced procedures on a mannequin or simulator and achieved a predetermined level of competency would feel more comfortable and make fewer mistakes when they moved onto real patients.
The results were impressive. An initial small observational study by Dr. Barsuk and colleagues showed that simulation-based training significantly improved third-year residents' proficiency in performing thoracentesis (Journal of Hospital Medicine, January/February 2008).
The medical community really took notice after Dr. Barsuk performed another study showing that catheter-related bloodstream infections declined after residents underwent simulation-based training in central venous catheter insertion (Archives of Internal Medicine, Aug. 10/24, 2009)—a hot-button issue since Medicare stopped reimbursing hospitals for preventable events such as central line-associated infections.
“Dr. Barsuk's and his colleagues' research yielded groundbreaking work in the use of mastery learning in simulation training,” said Mark V. Williams, MD, FACP, chief of Northwestern's division of hospital medicine, who nominated Dr. Barsuk as a top hospitalist. “He is now an acknowledged national leader in simulation training and development of innovative educational curricula.”
Not only did residents improve their skills and potentially improve patient outcomes through simulation training, they also loved the training itself.
“You might think that when you call a resident and say they didn't meet the minimum passing score, they wouldn't want to come back, but invariably they are very enthusiastic about getting the chance to practice more,” said Dr. Barsuk. “I'm asked all the time to expand the training to other procedures.”
The simulation method is emblematic of Dr. Barsuk's interactive teaching philosophy.
“A unique thing that I bring to the table is not just teaching the typical 1-2-3 steps,” he said. “I try to think about my clinical experience and where I've had problems in the past or where problems can occur, and teach to those areas.”
Dr. Barsuk's work with simulation training dovetails with his research interests in quality improvement and patient safety. As he demonstrated in the central line insertion training study, improving the effectiveness of resident training can lead directly to improvements in patient care and safety.
As an additional benefit, there is nothing like “knowing I am able to help shape the future of physicians and how they practice,” said Dr. Barsuk. “It's all worthwhile if, through what I do, I am making patient care safer and more cost-effective.”
Hospitalist hailed as hero after response to hometown tragedy
David Bowman, MD
Medical school: University of Arizona
Residency: University of Arizona
Title: Executive director, Tucson Region, IPC The Hospitalist Company
As executive director of IPC The Hospitalist Company's Tucson group, David Bowman, MD, expects to deal with difficult situations daily in the boardroom and the clinic. But perhaps his toughest challenge occurred away from the pressures of work, when the parking lot of his local supermarket became the site of a deadly mass shooting.
Dr. Bowman was the first physician on the scene of the Jan. 8, 2011 tragedy when a single gunman shot 19 people, killing six and critically injuring Rep. Gabrielle Giffords (D-Ariz), who had been holding a “meet and greet” in the supermarket parking lot.
“My wife and I had walked by Rep. Giffords on our way into the Safeway,” said Dr. Bowman. “Later, we heard the shots.” After rushing out of the store and surveying the scene, he went into field triage mode, assessing the wounded and assigning bystanders to stay with the injured and apply pressure to wounds.
“You just go to work…you start checking on people and if they're obviously dead, you step over them and go to the next one,” said Dr. Bowman. “You ask, ‘Are they bleeding? Are they breathing? Are they talking to you?’ and if they're not bleeding too badly and they're breathing, and nodding and responding, then you've got to get to the next one and try to work through whatever you can. I started going up the line, bending over talking to people—and some of them didn't answer back.”
Dr. Bowman's efforts helped many of the injured survive and he takes some comfort in knowing that everyone who survived their injuries that day was later released from the hospital. Those who lost their lives were already dead on the scene.
For Dr. Bowman, responding to the emergency was “doing what you're supposed to do as a doctor,” but many of his colleagues see him as a hero.
“Dr. Bowman saw what he did as something he does in the hospital on a daily basis: Use his medical skills and leadership to help the sick and injured,” said ACP Member Adam Singer, MD, CEO of IPC, who nominated Dr. Bowman as a top hospitalist. “But Rep. Giffords and the other people he aided at the scene that day know without a doubt that Dr. Bowman stepped up to a challenge well beyond what is taught in medical school or encountered in the hospital—and that makes him a hero.”
In the hospital, Dr. Bowman leads a team of more than 80 hospitalists who provide care at Carondelet St. Mary's Hospital and Tucson Medical Center in Tucson. He is credited with growing the Tucson group from about 12 hospitalists in 2000.
One key to his success is staying visible as both a physician and an executive, he said.
“I have to keep up my clinical skills and I have to be out there and visible and not sitting behind a desk,” he said. “You have to show the doctors that you're a doctor and show the hospitals that you know what's going on in their facilities.” To that end, Dr. Bowman often takes clinical shifts on nights, holidays and weekends when other physicians ask for time off.
Under Dr. Bowman's leadership, the Tucson group has improved patient safety, workflow and communication with outpatient physicians. For example, his group consistently achieves between 90% and 100% compliance scores on core measures for congestive heart failure at St. Mary's and, in the past five years, length of stay has fallen from 5.5 days combined for commercial and senior patients to 3.9 days for commercial and 4.3 days for seniors.
One of his most successful improvements was initiating a process for direct admission for referrals to the emergency department (ED). Under the program, patients referred for admission from small rural hospitals or physicians' offices can be approved for direct admission to the hospital instead of being evaluated in the ED upon arrival.
“If they're being sent from a rural hospital, for example, that initial evaluation [that they need hospitalization] could have been done, so why send them to the ED unless they're unstable?” he said. “Generally, the direct admission process unloads the ED and is much more convenient and fair to the patient, who doesn't have to lie on a hard stretcher but is instead in a bed, getting care.”
Dr. Bowman is currently working on a project to share best practices online across IPC's 350 hospitals in 23 states. If a hospitalist wants to know more about the best way to handle septic shock, for example, she could log onto IPC's Web site to check for best practices submitted by other groups, view the latest evidence and contact the physicians who posted the information.
“I like being part of a system that is technologically advanced and can disseminate good information to the doctors in a rapid manner,” Dr. Bowman said. “We all have a tendency to think about what we're doing at our own facility, but if we can put it all together into a bigger segment, everyone benefits.”
Post-discharge follow-up, team care help prevent readmissions
Jon D. Desilets, MD
Medical school: University of Southern California
Residency: Harbor-University of California, Los Angeles Medical Center
Title: Assistant area medical director, assistant chief internal medicine and local and regional chief of hospitalists, Kaiser Permanente's Los Angeles Medical Center
When patients are discharged from Kaiser Permanente's Los Angeles Medical Center (LAMC), they leave armed with all of the prescriptions, instructions and follow-up appointments needed for a successful recovery. But Jon D. Desilets, MD, and his hospitalist team know that providing information is only the first step in heading off problems that can lead to some patients being readmitted within a month.
“There are a lot of things that have to happen within the first seven days after discharge,” said Dr. Desilets, who started the hospitalist program at LAMC in 2004. “We have to ensure a smooth transition from the inpatient to the outpatient setting and provide appropriate information to patients and their primary care physicians.”
In his role as regional hospitalist coordinating chief for Kaiser's Southern California region, Dr. Desilets is leading the Safe Transitions Avoiding Readmissions (STAR) program at LAMC. Key elements of the Kaiser-developed program include calling the patient within 48 hours of discharge, booking a primary care follow-up appointment at discharge, and improving communication between hospitalists and primary care physicians.
For Dr. Desilets, providing support after discharge is an extension of a proactive approach to care that begins at admission.
“We need to think about what patients need upfront early in their hospital stay,” he said. “When everything is done in a timely way with good physician communication, it leads to shorter stays and better outcomes.”
To ensure that patients' needs are met during their stay, Dr. Desilets launched a team-based model that assigns a case manager to individual medical teams, as opposed to units.
“Instead of having a case manager that's interfacing with multiple different doctors, this way they work with the same group of doctors consistently over time and the same patients from admission to discharge,” he explained. “The continuity is very effective.”
Under the team model, attending physicians and house-staff meet with case managers twice daily to discuss their assigned patients. In addition, a LAMC physician and nursing director make rounds three times a week to discuss all cases and get an update on any diagnostic tests or procedures that will be needed during a patient's stay. The team members then follow up with appropriate departments, such as diagnostic imaging, to ensure that needed studies or tests get scheduled as soon as possible.
Besides improving the patient stay, the model dovetails with LAMC's role as a major teaching hospital.
“These rounds help educate and keep our efficiency principles in the minds of our physicians,” said Dr. Desilets. “They have to be constantly aware of what they're doing and why and what the inpatient needs are.”
Dr. Desilets tries to foster the same proactive approach when serving as attending on the inpatient teaching services, which he does for about five months out of the year.
“When I'm working with residents, I hear them out first and then give them feedback on whether I would handle the case differently,” he said, “as opposed to hearing the case and telling them what to do.”
While it's often easier to take the latter approach in a busy hospital, it's not as conducive to learning.
“It's important to let residents fully articulate their thinking,” he said. “I let them formulate their ideas and plans and generate a differential diagnosis and tell me what they think the best course of action is. Then I step in and educate them about what they need to refine or what they overlooked.”
Residents seem to like his approach, as Dr. Desilets has twice been named Outstanding Teaching Attending of the Year over the past 12 years. For Dr. Desilets, teaching is about training residents how—not what—to think.
“We have to balance appropriate residency supervision with independent thinking and autonomy,” he said.
From the ED to the operating room, going the extra mile
Vercin Ephrem, MD, ACP Member
Medical School: Lebanese University Faculty of Medical Sciences
Residency: Staten Island University Hospital
Title: Director of hospital medicine, Lakes Region General Hospital, Laconia, N.H., and Huggins Hospital, Wolfeboro, N.H.
It was 3 a.m. when a fit man in his early forties arrived in the emergency department for the second time that day complaining of severe pain in his left calf following a fall from a ladder a week before. The physician on call was leaning toward prescribing antibiotics for possible underlying infection until he consulted with hospitalist Vercin Ephrem, MD, ACP Member, who suspected something more serious—suspicions that led to saving the man's leg.
“The man was a marathon runner and very healthy,” said Dr. Ephrem, director of the hospitalist program at Lakes Region General. “His leg was hard and the calf was red but there was no evidence of a puncture wound. My concern was that he had a compartment syndrome due to trauma from his fall.”
The orthopedic surgeon on call that night advised initially prescribing antibiotics until he could examine the patient hours later after finishing his surgery, so Dr. Ephrem called a vascular surgeon who agreed to examine the patient immediately. When they saw that the pressure in the posterior compartment was 80, the man was rushed to the operating room.
“The leg was almost exploding, literally,” said Dr. Ephrem. A fasciotomy relieved the pressure and the man was feeling better the next day, but without prompt treatment he likely would have lost his leg.
While not every case ends so well, Dr. Ephrem tries to head off missteps by taking the time to look beyond the obvious.
“You have to do more than just look at the symptoms; you have to listen to the patient,” he said. “In this case, his wife said her husband was not a complainer and it took a lot for him to come back to the ED. He was a runner, really healthy and there was no puncture wound—these were all red flags.”
Besides his diagnostic skills, Dr. Ephrem is known by colleagues for his strong work ethic and commitment to improving the quality of patient care. Since starting Lakes Region's hospital medicine program six years ago, he has grown it to nine hospitalists and expanded services to a nearby community hospital, Huggins Hospital.
In 2009, Lakes Region became the first hospital in New Hampshire to participate in Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), a program developed by the Society of Hospital Medicine to improve transitions at discharge with the goal of reducing 30-day readmission rates. Under Dr. Ephrem's guidance, the hospital was able to reduce readmissions in its 20-bed elder care unit from 7% to 2% in one year.
“Medicaid saw our numbers and approached and offered to help us extend BOOST into the entire state,” said Dr. Ephrem. “Now we're modifying and expanding the program to make every patient, not only elderly ones, a BOOST patient to prevent readmissions of all patients.”
Under BOOST, hospitals identify patients at high risk of readmission based on factors such as problem medications, diagnosis, health literacy and social support. The hospital team then tries to address and mitigate those risks during hospitalization, prepare detailed discharge instructions, and schedule outpatient follow-up visits and calls.
Dr. Ephrem is now expanding the program to nursing homes in the region. The idea is to create stronger ties with long-term care facilities in order to prevent unnecessary readmissions when patients have problems.
For example, if a patient sent to a nursing home after a hip replacement surgery develops a urinary tract infection, she is usually readmitted to the hospital, said Dr. Ephrem. But such cases often can be handled at the nursing home.
“The nursing homes have the capacity to place intravenous access and administer antibiotics, so instead of sending patients back to the hospital, they can be treated there,” he said. “I expect we can decrease those types of readmissions by 5 to 6% by having outreach to the nursing homes.”
Project BOOST provided a framework for improvement at Lakes Region, but it was Dr. Ephrem's leadership that ensured its success, said Ellen Wolff, administrator of the hospital medicine program at Lakes Region.
“In addition to decreasing readmission rates under 30 days due to the discharge planning that is included in the [BOOST] program, he has also been able to reduce our length of stay and still provide safe, quality patient care,” she said. “We were one of only 39 hospitals that received [the Medicare] grant and it is because of Dr. Ephrem's efforts.”
Bedside teaching benefits residents and patients
Kathlyn E. Fletcher, MD, ACP Member
Medical school: University of Chicago Pritzker School of Medicine
Residency: University of Chicago
Title: Associate professor of medicine, Medical College of Wisconsin
When ACP Member Kathlyn Fletcher, MD, first began leading rounds at the Milwaukee VA Medical Center, she noticed that residents were reluctant to enter patients' rooms, preferring to discuss the case while standing in the doorway. That's changed under the leadership of Dr. Fletcher, who believes that teaching at the bedside benefits both patient and resident.
“Often, teams will stop at the doorway, discuss all findings and updates about the patient and the care plan, then walk in, do a quick exam and leave,” said Dr. Fletcher, who established the medical center's hospitalist program almost two years ago and grew it to eight hospitalists with 24/7 coverage. “We move all of that work to the bedside so the patient actually hears how we talk about them and gets to give input into what they think of our plans.”
Many residents are initially nervous about going into the room but they usually end up liking the opportunity to interact more with patients, she said.
“We aren't necessarily spending more time on the patient but we're spending more time with them,” Dr. Fletcher said. “And I think it's good for the patient to see that.”
For Dr. Fletcher, supervising a team of residents is one of the most satisfying aspects of leading the Milwaukee VA's hospitalist program, which is affiliated with the Medical College of Wisconsin.
“[Working with residents] gives us much more exposure to the medical education side of things, which is good for us and our practice because we learn from the residents as well as teach,” she said. “And it helps out the hospital to know that they have one resident team that's consistently covered.”
Resident education has also been the focus of much of Dr. Fletcher's academic research. She has authored several studies on the impact of resident work hour regulations on patient safety and resident education, including one study published earlier this year which concluded that patient mortality and resident well-being have improved since the 2003 duty hour changes that limited interns' shifts to 16 hours and night floats to six consecutive nights.
An earlier study published in Annals of Internal Medicine (Dec. 7, 2004), in which Dr. Fletcher and colleagues examined the evidence on whether the new work hour rules would improve patient safety, had a profound impact on the direction of her future research.
“That project, in some ways, formulated the rest of my career,” said Dr. Fletcher, who is now examining the issue of patient safety from another angle: discontinuity of care. A study published in the April 22, 2009, Journal of the American Medical Association found that discontinuity of care between outpatient and inpatient settings declined substantially between 1996 and 2006, largely due to the rise of hospitalist services. She is currently working on a related study, funded by the VA, investigating the relationship between number of physician handoffs during a patient's stay and bad outcomes.
Dr. Fletcher is also engaged in a project that aims to measure the workload of an inpatient physician and how much time residents and hospitalists spend on various tasks. For example, how much time does a hospitalist spend at the bedside versus at the computer writing orders? And how should hospitalist services account for multi-tasking or factor in the relative difficulty of different tasks?
“Once we understand the workload better, we can figure out a better way to allocate patients between physicians,” said Dr. Fletcher. “We can structure the work so that it's better for physicians and patients.”
In her own workload, Dr. Fletcher said she has achieved a perfect balance.
“I get to spend time directly taking care of patients myself; I get to supervise residents taking care of patients; and I get to teach and do research … and in between those things I get to do the administration for the hospitalist team,” she said. “I have this ideal job where everything is balanced and everything is interesting.”
Patients benefit from added support after discharge
Sunil Kripalani, MD, ACP Member
Medical school: Baylor College of Medicine
Residency (and fellowship in hospital medicine): Emory University
Title: Chief, section of hospital medicine, Vanderbilt University
Like many physicians, Sunil Kripalani, MD, ACP Member, becomes frustrated when recently discharged patients show up in the emergency department. But while others may blame the patient, Dr. Kripalani worries about systems and standards of care. He suspects that patients would do better if clinicians provided more education and support during and after discharge.
Dr. Kripalani is testing that theory by conducting randomized controlled trials of individualized counseling and self-management tools in the post-discharge period, with the goal of helping patients adapt to their new medication regimens more successfully. As principal investigator of the Pharmacist-Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study, he believes patients will benefit from the extra support.
“It's very common for regimens to change during hospitalization, but it's not always clear to patients what those changes are and why they were made,” said Dr. Kripalani. “Our intervention sought to improve patients' understanding of their medications, clear up discrepancies in their medication lists and support them in that early post-discharge period.”
For Dr. Kripalani, the study encapsulates his core research interests over the past decade: health literacy and care transitions.
“I've practiced in very different environments ranging from a county hospital to tertiary care and veterans' hospitals and I've found that the transition of care remains difficult across all of these settings,” he said. “There are so many opportunities to improve the way we structure the process of care at discharge and beyond.”
In the PILL-CVD study, which is pending publication, patients received tailored counseling from a pharmacist in the hospital, focusing on any medications changed during hospitalization. Patients were then sent home with an easy-to-understand illustrated medication card and they received follow-up care via phone to discuss any problems, new symptoms or side effects.
“Patients often need help managing their medication regimen, especially at points of transition like hospital discharge,” said Dr. Kripalani. “We have seen across several studies that providing easy-to-understand patient education tools helps reduce medication discrepancies, improve understanding, and improve adherence, particularly for at-risk patients with low health literacy or cognitive impairment.”
He has been working to translate those findings into practice as co-founder of a private company, PictureRx, that develops illustrated patient education tools for patients with low health literacy or limited English proficiency.
Dr. Kripalani is serving as co-investigator of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), sponsored by Brigham and Women's Hospital in Boston. Vanderbilt, in Nashville, Tenn., is one of nine collaborating institutions in the study, which aims to develop a safer, more accurate medication reconciliation process for admission and discharge and implement it at six U.S. hospitals.
He is also the principal investigator on the new Vanderbilt Inpatient Cohort Study (VICS), which will enroll 3,000 patients hospitalized with acute coronary syndromes during the next four years. “This study will help us understand how a broad set of psychosocial factors influence outcomes after discharge, including quality of life and health care utilization,” he said.
Dr. Kripalani's collaborative approach to research extends to his leadership style. Since taking over Vanderbilt's hospital medicine section four years ago, he's grown the program from three to 16 hospitalists, plus three acute care nurse practitioners, and extended hospitalist services beyond Vanderbilt University Hospital to Vanderbilt's rehabilitation hospital and the Nashville Veterans Affairs Medical Center.
Dr. Kripalani views growth as a series of new partnerships in which hospitalists can enhance, rather than replace, existing programs.
“When we started growing hospital medicine here, there were already many other quality improvement, education, and informatics programs,” he said. “I tried to reach out to my colleagues in those areas to better understand their approaches and figure out how we can add value, rather than trying to replace something that others are already doing well.”
Jeffrey L. Schnipper, MD, ACP Member, a colleague who has collaborated with Dr. Kripalani on several research projects and nominated him as a top hospitalist, calls Dr. Kripalani a “natural born leader.”
“The success of the hospital medicine program at Vanderbilt University is due to him being the kind of leader and effective communicator that others want to work with,” said Dr. Schnipper. “I have seen firsthand his ability to provide outstanding opportunities for professional growth, to help advisees navigate the difficult waters of academic medicine, and to provide sage advice on how to conduct clinical research projects. He simply makes those around him better.”
Reaching out to help underserved patients manage their health
Valerie Press, MD, ACP Member
Medical school: University of Michigan
Residency: University of Chicago
Title: Instructor, University of Chicago Pritzker School of Medicine
As a resident at the University of Chicago, Valerie Press, MD, ACP Member, attended a “diabetes camp” where she practiced using a blood glucose meter and followed blood sugars twenty-four hours a day for active teen campers. Medical schools rarely train in such real-life settings—especially for medications that require devices for dispensing to patients—but the camp's lessons have proved invaluable to her work as a hospitalist, she said.
“There are so many details that we just don't get taught,” said Dr. Press, who came to the University of Chicago over seven years ago as a resident and is now in her third year as a faculty member. “Unless you do experiential learning, it's really hard to relate to patient concerns and difficulty with self-management of their chronic diseases.”
Over the years, Dr. Press has led workshops in underserved neighborhoods, trained residents in patient self-management techniques and tested new inpatient education techniques, bringing her trademark passion and enthusiasm to each new project.
“Dr. Press has been a leader in advocating for improving health disparities through better patient education in both the hospital and the community,” said Vineet Arora, MD, FACP, who mentored Dr. Press during residency and nominated her as a top hospitalist. “She demonstrates tremendous dedication and passion in her education, research and clinical roles.”
Dr. Press' interest in health literacy and health disparities was sparked during her residency when she joined the Neighborhood Health Exchange (NHE) project, led by Dr. Arora. The grant-funded project focused on educating residents about working with patients with chronic diseases, particularly diabetes and hypertension.
Dr. Press helped set up a partnership with Chicago's Hyde Park neighborhood group and led monthly educational seminars for community members. Her success with the NHE project led to her involvement with a spin-off called “The Chicago BREATHE Project: Teaching Internal Medicine Residents to Improve care for Asthmatics,” funded through the ACP Foundation's health literacy awards program.
Dr. Press led educational sessions at community centers in underserved areas of Chicago and led educational sessions for residents at five Chicago academic medical centers. The project was well-received by the community, but also beneficial for the residents involved, she said.
“I learned early on in my experience with community service that we gain as much if not more than the community members,” she said. “As residents, when you teach, you learn. We were exposed to questions that were eye-opening, making us realize that we can forget how much patients want to know about their diseases.”
Dr. Press also helped develop innovative educational videos and toolkits to improve inpatient asthma education that are available on the Chicago BREATHE and the Doctor's Channel Web sites.
The main focus of her current and recent research is determining the prevalence of respiratory inhaler misuse and poor health literacy among inpatients, and developing effective hospital-based educational strategies to improve self-management. She is working on a series of hospital-based studies to test the effectiveness of the “Teach-to-Goal” technique in educating inpatients to use inhalers, and will compare the technique to briefer interventions. She will also determine whether level of health literacy might help dictate the type of educational strategy to use with patients who need inhalers.
Over the past year, Dr. Press has been part of a team with Dr. Arora and others to develop and implement a checklist for physicians on the general medicine ward that focuses on improving adherence to four critical patient care elements: immunizations (vaccination for pneumonia), bedsores (heel and sacrum skin exams for pressure ulcers), catheters (restriction and removal of urinary catheters) and deep vein thrombosis (pharmacologic prophylaxis).
“This project is very exciting because it bundles these really high-level items that all help reduce morbidity and mortality,” said Dr. Press.
Only two months after the checklist was implemented, overall adherence to the four processes of care rose by 20%, one of the most rapid changes to occur at the hospital. The checklist has since become fully integrated into the hospital's online documentation.
“It's inspirational to see how change can be taken up,” said Dr. Press. “For example, it used to be that a lot of residents weren't asking about whether patients needed a pneumococcal vaccine. Now, by the next morning after admission, [attendings] can see that residents have already incorporated all of these things [on the checklist] into the patients' care.”
Teaching residents to think critically and connect with patients
Michelle Rossi, MD, FACP
Medical school and residency: University of Florida College of Medicine
Title: Associate program director of internal medicine residency program, University of Florida and academic hospitalist, Malcolm Randall VA Medical Center, Gainesville, Fla.
As faculty on an innovative procedure service team at the Veterans Administration hospital in Gainesville, Fla., Michelle Rossi, MD, FACP, is charged with training residents to perform invasive bedside procedures safely and effectively. But just as important as knowing how to perform a lumbar puncture or a thoracentesis, she tells residents, is knowing when not to perform one.
“I sometimes tell a patient, ‘I enjoy procedures and I love to teach but my ego is not nearly so important as your health,’” said Dr. Rossi. “As physicians we need to ask whether this is the right procedure for the right patient at the right time.”
Encouraging residents to think independently and critically is a hallmark of Dr. Rossi's teaching style.
“The best instruction is when our trainees feel comfortable to exercise their own judgment and decision making because they know they're in a supportive environment,” said Dr. Rossi. “I listen to their thinking and we decide on the best course of action together.”
At the bedside, Dr. Rossi asks residents to share what they think and why, then challenges them to strengthen the rationale for their management plan with physical exam results or objective data. She encourages them to draw “medically defensible and reasonable” conclusions, even if they are not the same as her own.
“I share my perspective on what I would do but I grant them the latitude to exercise their own developing clinical judgment,” she said. “I want to demonstrate that they don't have to be a ‘mini me,’ that they should develop their own clinical instincts.”
Along with encouraging critical thinking, Dr. Rossi urges residents to make personal connections with patients at the bedside. On rounds, she introduces residents to each patient and she prefers to sit or kneel at the bedside while instructing so she can touch and converse with the patient.
“Taking a few moments to listen to patients enriches the whole process,” said Dr. Rossi. “Not only is this an intellectual challenge for residents but also an emotional, spiritual encounter where the patient is trusting us with his or her most vulnerable moments.”
Dr. Rossi instructs residents not only to listen but also to observe the patient for body language that might indicate anxiety or lack of comprehension. When patients perceive that a physician is caring and attentive, they are more likely to talk about issues that they find embarrassing or confusing, which may impact decisions about their care.
Communication is “transformative” at the bedside, added Dr. Rossi, even when a patient's condition resists treatment.
“I tell residents that we are called to cure but we do not always have the ability to do so,” she said. “When we cannot, we should have the courage to comfort our patients and take the time to listen. There is always the opportunity to provide sympathy, empathy, understanding, compassion and palliative medical management.”
In addition to teaching on the inpatient service, Dr. Rossi often mentors students or residents who are interested in health care advocacy. She travels with resident representatives to ACP's Leadership Day in Washington, D.C. and on legislative visits to Tallahassee.
“Dr. Rossi is an exemplary model of leadership,” said ACP Associate Member Morganna Freeman-Keller, DO, a colleague and mentee. “She seeks resident and program leadership input in developing innovative programs for resident education, patient safety, and patient advocacy and she's well-known for her approachability and warm demeanor.”
In fact, Dr. Freeman-Keller is one of her mentorship success stories, said Dr. Rossi. After working with Dr. Rossi for several years on advocacy issues, Dr. Freeman-Keller last year applied for and was selected as the recipient of ACP's first health policy internship for associates.
“It was exhilarating for me because I felt so humbled and honored to have played a small part in her success,” said Dr. Rossi, who is Governor-Elect for the Florida Chapter. “Seeing my students and residents succeed is very gratifying to me.”
Partnerships inside and outside the hospital help lower readmissions
Julius Yang, MD
Medical school: University of Massachusetts
Residency: Beth Israel Deaconess Medical Center
Title: Director of inpatient quality, Beth Israel Deaconess Medical Center; assistant professor of medicine, Harvard Medical School
As co-leader of his Boston facility's participation in an Institute on Healthcare Improvement (IHI) collaborative to reduce readmissions, Julius Yang, MD, discovered that some problems are difficult to solve from within. To truly understand what drives avoidable readmissions, you have to know what happened to the patient inside and outside of the hospital.
“Our typical approach in trying to fix problems is to gather hospital personnel together to problem solve, but especially for this problem of readmissions, we recognized that we would need to partner with groups outside of our hospital,” said Dr. Yang, who leads a cross-continuum committee as part of the hospital's involvement with the IHI's State Action on Avoidable Rehospitalizations (STARR) initiative. “We have so many partners outside the hospital who are in the home and can give us direct information about things like how the patient manages their pills everyday.”
The cross-continuum committee is composed of primary care physicians, hospitalists, inpatient and visiting nurses, case managers, social workers, and representatives from post-acute care facilities. Colleagues have been impressed with Dr. Yang's ability not only to put the committee together but also to actively engage all participants.
“I recently attended one of his committee meetings and was struck by the number and breadth of caregivers in the room, all of whom were actively engaged in how to decrease our number of readmissions and the quality of the handoff at discharge,” said ACP Member Anjala Tess, MD, a colleague who nominated Dr. Yang as a top hospitalist. “The level of discussion and his ability to engage every discipline in the room was remarkable.”
After years working as a hospitalist, Dr. Yang assumed he knew what type of care patients need after they leave the hospital, but the IHI committee has given him new insight.
“As hospital personnel we end up focusing on the care we provided,” said Dr. Yang. “When our plan keeps on failing we beat ourselves up a bit or blame the patient for not listening to our instructions…but when we present a case to a wider group, the visiting nurse often can fill in the logistical details that make all the difference between a plan working and a plan failing.”
The IHI project has also given him a greater appreciation for the decision making that takes place outside of the hospital, he said. Nurses in long-term care facilities, for example, need to know more than instructions on medications; they should be made aware of the overall plan of care and goals for a patient.
It is helpful for the nurse to know, for example, if a family of a patient with end-stage heart failure requests that all efforts be made to keep the patient at the long-term care facility rather than spend his last days in the hospital. In some cases, the referring hospitalist might plan medications to prevent readmission, but not clearly communicate the family's request.
“We give directions on what medications to give, what frequency, wound care, etc., but the nurses want to understand what we are trying to achieve and what's realistic,” explained Dr. Yang. “If the patient does get worse at the extended care facility and if I don't give them guidance, they'll just send the patient back to the hospital, whereas if I emphasized how strongly the patient's family felt about staying outside the hospital, they might be able to change their treatment plan in order to honor that.”
Dr. Yang has been involved with numerous other quality improvement projects, including creating a purely electronic signout process that has speeded the transfer of patients from the ED to the medical service, and a geographic admitting system that has led to more efficient workflow by assigning hospitalists and housestaff to “home units” instead of taking care of patients on multiple floors.
The success of these projects is largely due to Dr. Yang's leadership style, which combines a willingness to think outside the box and make tough decisions with a rare ability to listen and take other perspectives into account, Dr. Tess said.
For Dr. Yang, listening is the natural path to truly understanding a problem and arriving at an effective solution. And the key to implementing that solution is usually collaboration.
“Whether it's partnering with nurses on the floor or the ED on handoffs or post-acute care facilities after discharge, it's all about putting people together who are trying to accomplish the same thing,” he said. “If we can work together, we can make patient care better.”