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Meet our 2012 Top Hospitalists
|2012 Top Hospitalists:|
Welcome to our fifth annual Top Hospitalists issue! We're thrilled to recognize the impressive work of the 10 physicians profiled on the following pages. Our call for nominations last spring yielded a record number of responses from peers, supervisors, mentors and mentees. ACP Hospitalist's editorial board members then reviewed the nominations and selected the Top Hospitalists, who have truly distinguished themselves in areas including patient safety, community involvement, clinical skills, quality improvement, leadership and teaching.
We hope you find it as inspiring as we did to read about these remarkable individuals, and we 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.).
Communication skills drive success
Alexander R. Carbo, MD, FACP
Medical School: Johns Hopkins University School of Medicine, Baltimore
Residency: Beth Israel Deaconess Medical Center (BIDMC), Boston
Title: Hospitalist, BIDMC; assistant professor of medicine at Harvard Medical School
The medical staff at BIDMC knows Alexander R. Carbo, MD, FACP, as a top clinician and educator with a passion for quality improvement, but he may be most appreciated for his skills as a communicator.
“I talk to the nurses, which is sometimes viewed as novel,” said Dr. Carbo. “Nurses have valuable information that physicians wouldn't easily have access to. That partnership goes a long way but it tends to be vastly underappreciated by physicians.”
BIDMC's nursing and rehabilitation clinicians, however, haven't hesitated to show their appreciation for Dr. Carbo's collaborative style by voting him Hospital Medicine Clinician of the Year three times since 2009. In addition, Harvard medical students voted him best clinical instructor at BIDMC in 2011 and 2012.
Patients and families, too, appreciate Dr. Carbo's straightforward communication style, said Mark Aronson, MD, MACP, interim division chief of general medicine and primary care at BIDMC.
“Dr. Carbo has taken on the difficult role of representing the department of medicine in meetings with families in whom a loved one suffered an adverse event,” said Dr. Aronson. “He is a model of dignity, thoughtfulness and compassion in his dealings with these difficult matters. His ability to explain complex medical decision making to patients and their families is remarkable.”
Following a recent lecture on quality improvement, a student in the audience approached Dr. Carbo to discuss a case involving a potential delay in diagnosis. Recognizing the importance of the case, Dr. Carbo shared the details with colleagues in other departments, who created a new protocol to help avoid diagnostic delays.
“People call me a connector,” Dr. Carbo said. “I listen and recognize when something is important. I connect patients to their disease process or nurses to interns or surgeons to family members.”
Dr. Carbo also connects several quality improvement groups in the hospital. One is as a faculty mentor for the Stoneman Patient Safety rotation, a required three-week introduction to patient safety and quality improvement for junior and senior residents created by Dr. Kenneth Sands, senior vice president of healthcare quality at BIDMC, and currently organized by Anjala Tess, MD, ACP Member, a 2010 Top Hospitalist.
During the rotation, small teams of residents work with faculty mentors to analyze actual near-miss or adverse events and design processes for improvement that often result in real changes in the hospital. The residents try to pinpoint contributing factors and devise next steps to prevent a recurrence; they present their findings at the Medical Peer Review Committee, which Dr. Carbo chairs.
“The rotation is about taking a process that is sometimes unclear and trying to figure out what is the workflow, what are the essential steps and how do we make this a better process than what we have now,” Dr. Carbo said.
“It has been very enjoyable to take errors or adverse events and translate them into actionable items that will protect patients down the road,” said Dr. Carbo. “The residents love it when their projects result in tangible changes to protect patients in the future.”
While Dr. Carbo finds the work rewarding, it is far from easy and calls for exceptional communication and negotiating skills, according to Dr. Aronson.
“The Medical Peer Review Committee is an extremely sensitive multidisciplinary meeting in which medical mishaps and errors are discussed,” he said. “Dr. Carbo prepares in a diligent manner, having reviewed each case thoroughly and often meeting with discussants. From these efforts, literally dozens of quality improvement initiatives have emerged and Dr. Carbo's role is invaluable.”.
Improving care for poor patients
Honora L. Englander, MD, ACP Member
Medical School: University of Massachusetts, Worcester
Residency: Oregon Health & Science University (OHSU), Portland, Ore.
Title: Assistant professor of medicine, OHSU
As a free-clinic volunteer during medical school, ACP Member Honora L. Englander, MD, saw firsthand how poor and vulnerable patients often fell into a hopeless cycle of illness and despair after leaving the hospital. But while others viewed it as an intractable dilemma, Dr. Englander began to envision change.
That vision became a reality during her job as a hospitalist at OHSU, where she created the Care Transitions Initiative (C-TraIn). The program is noteworthy not only for its success with helping poor and uninsured patients transition between hospital and outpatient settings, but also for garnering the financial support of the hospital. (ACP Hospitalist covered C-TraIn in its March 2012 issue.)
“To ensure integration with hospital efforts and increase program sustainability, Honora pursued hospital funding rather than grants,” said Rebecca Harrison, MD, OHSU's section chief for hospital medicine who co-nominated Dr. Englander as a Top Doc. “That she developed a quality and business case and developed new clinical partnerships that bridge hospital and community care demonstrates her desire to solve substantive problems.”
The key to her success, Dr. Englander said, is a natural sense of optimism combined with dogged persistence.
“To me, it just made sense and I didn't see it as hard,” she said. “We went on to have all kinds of challenges that I didn't necessarily expect but I have a combination of persistence and curiosity, and I really believed in what we were doing.”
C-TraIn began with a single morbidity and mortality conference in 2008 convened by Dr. Englander and her colleague Devan Kansagara, MD, FACP. They highlighted the story of an uninsured middle-aged man who, after being treated in the hospital for pneumonia and several comorbid illness, was discharged without any plan for follow-up care or means to pay for his prescribed medications. At home, his health declined, he lost his job and housing, and he eventually landed back in the hospital for a 19-day (unreimbursed) stay.
The story was frustratingly familiar to attendees, but Dr. Englander added a new perspective by inviting a hospital administrator to share cost data on the financial implications to the hospital. Although it was the first of many meetings, the conference planted the seeds for C-TraIn's launch two years later.
The most novel aspect of C-TraIn is its financing. OHSU pays three community clinics to serve as primary care medical homes for poor and uninsured patients after discharge, and patients are given 30 days of free prescription medications. After that, patients pay $4 per month for medications or access medicines through free or low-cost clinic pharmacies. Patients also get help from a transitional care nurse who coordinates care inside the hospital, makes home visits, and acts as a liaison with the primary care clinic.
“The program really does shift in a fundamental way the role of the hospital in caring for these patients,” said Dr. Englander. “It's extremely gratifying to see what can happen when there's an integrated system that provides the care that patients need.”
Dr. Englander's model has been so well received that she has been asked to help the regional Coordinated Care Organization expand the C-TraIn concept as part of health care reform in Oregon. According to one colleague, Dr. Englander's success stems from her ability to bring diverse groups together around a common purpose.
“Honora makes it easy for stakeholders to understand why these efforts matter and how patients can benefit,” said Dr. Kansagara, assistant professor of medicine at OHSU and a staff physician at the Portland VA medical center. “She really understands that people are naturally motivated to work hard for a common purpose when they can see that the work they are doing matters and has tangible effects.”
Perhaps most important, Dr. Englander keeps herself and others focused on the overarching goal of improving patient care.
“Honora is a remarkably humane person and this comes through in how she treats her patients, colleagues from all disciplines, and also how she treats the work of systems change itself,” said Dr. Kansagara. “I think people naturally want to work with someone who has an action-oriented vision for improvement, and who is always keeping the ball moving forward.”.
A practical approach to teaching
Nita S. Kulkarni, MD
Medical School: Washington University School of Medicine, St. Louis
Residency: Northwestern University, Chicago
Title: Assistant professor, Northwestern University Feinberg School of Medicine; medical director of physician assistant program, Northwestern University
Back when she was a medical student, the world of evidence-based medicine (EBM) felt like a blur of incomprehensible statistics to Nita S. Kulkarni, MD. But flash-forward a few years and EBM is at the core of her work as a teacher and clinician at Northwestern University.
“I teach EBM that is clinically relevant and useful in day-to-day practice,” said Dr. Kulkarni. “Clinicians don't really need to know extensive statistics; they need to know how to look at an article and analyze it and use the information in their clinical work.”
To that end, Dr. Kulkarni tries to get EBM lessons across in practical, manageable pieces. Instead of a lengthy lecture, she might teach an impromptu five-minute lesson while rounding with residents on the wards.
“The residents especially like that approach,” she said. “They're getting information they can use but they're not tied down sitting for an hour of teaching.”
Dr. Kulkarni takes a similarly practical approach to teaching as medical director for Northwestern's physician assistant (PA) program. She developed a first-year course on EBM that asks PA students to analyze clinically relevant studies and present them to their peers along with a POEM (patient-oriented evidence that matters), a short summary that pulls out the essential clinical question and the takeaway message or bottom line.
Dr. Kulkarni is a regular contributor of POEMS to the Journal of Hospital Medicine and the online publication Essential Evidence Plus. For PA students, writing POEMS develops critical appraisal and presentation skills that will help them with their master's thesis projects at the end of their second year.
Dr. Kulkarni's innovative approach to teaching and involvement with the PA students is remarkable, said Jim Van Rhee, MS, PA-C, Northwestern's PA program director.
“In her three years as medical director, she has taught the students the importance of applying evidence-based principles to clinical practice, developed a student journal club, assisted with clinical site recruitment, and assisted clinical year students with the development of their internal medicine knowledge and skills,” said Mr. Van Rhee. “In my 16 years of PA education I have never had a medical director so involved with the education of the PA students and in assisting the faculty in the development of the program's innovative curriculum.”
In addition to her work with the PA program, Dr. Kulkarni serves as a unit medical director at Northwestern Memorial Hospital, where she helped spearhead an initiative that dramatically improved patient satisfaction scores. The improvement was all the more impressive considering that the unit houses some of the sickest, most difficult to manage patients in the hospital.
Working closely with the unit's nurse managers, Dr. Kulkarni said she implemented a lot of “little changes” aimed at improving the work environment for clinicians while boosting the quality of care. For example, certain hospitalists were dedicated to the unit so they could develop ongoing relationships with the nurses, and Dr. Kulkarni maintained a constant presence, frequently sitting in on multidisciplinary rounds.
“I provided continuity for the hospitalists who were rotating through the unit every week,” she said. “I gave them background on patients and also played a troubleshooting role when issues or complaints arose with patients and families.”
As a result of her collaboration with the unit's nurse managers, the unit went from having some of the lowest Press-Ganey patient satisfaction scores to winning a patient satisfaction award.
Another key to Dr. Kulkarni's success in improving patient satisfaction is her caring attitude toward patients, said her supervisor and Top Docs nominator Mark V. Williams, MD, FACP. As evidence, he provided an excerpt from a patient letter to the hospital's chief operating officer:
“Dr. Kulkarni made me feel part of the process instead of a subject of the process,” the patient wrote. “She clearly explained my illness, potential risks, the course of treatment, expected stay length, outpatient follow-up and future strategy. Her attention to my needs and comfort is what one might expect from a five-star hotel concierge.”.
Creating a path for future leaders
Diana Mancini, MD
Medical School: University of Colorado Denver
Residency: University of Colorado Denver
Title: Associate program director of the internal medicine residency program, University of Colorado; hospitalist, Denver Health Medical Center.
Diana Mancini, MD, and her husband Sam Mancini, a business owner, thought they were on the same page when preparing to co-lead a leadership seminar for hospitalists on emotional intelligence. It wasn't until they began to pull up their separate slides that they realized they had gone in totally different directions with the topic.
“I created an entire talk on the amazing brain physiology of emotional inhibition, from neural transmitters to advanced thought processing, while Sam focused on a cognitive action plan for functioning in complicated work environments,” said Dr. Mancini. “My focus was theory and anatomy, while his was entirely tactical action plans.”
Residents loved the results, and the Mancinis went on to create a two-year curriculum on leadership, one of three resident training pathways (along with research and clinical) at Denver Health. The idea is to expose physicians to real-world business strategies to make them more effective medical leaders.
“Prior to this pathway being created, there was absolutely none of this information incorporated into the training of either medical students or medical residents,” said Jonathan Schwartz, MD, the current Chief Medical Resident at Denver Health who trained under Dr. Mancini and was her Top Doc nominator. Residents typically are shielded from the politics of leadership during training, he said, but while that allows them to focus on their clinical skills, it also “leaves a large gap in a skill set necessary for navigating work life after training.”
As a result, said Dr. Schwartz, “many people opt to either avoid leadership positions entirely, are passed up for such positions as they are deemed unfit because of lack of skills or, worse, they are promoted to leadership positions and are ineffective in those roles.”
Dr. Mancini has also relied on proven business strategies to streamline workflow and processes throughout the hospital. For example, she incorporated lean manufacturing processes into a new system of geographic rounding that allowed residents to see all of their patients on one floor instead of rounding on nine different floors spread among three towers.
“[Geographic rounding] has kept nursing staff with the residents they are familiar with and promoted a multidisciplinary community that is hard to promote when people are scattered throughout the hospital,” said Dr. Mancini. It has also translated into better care for the sickest patients.
“The number of rapid response calls we've had for vital sign abnormalities has dropped dramatically because residents are there on the floor if something happens,” she said. “Patients don't get to as severe a state because everyone is there to provide care and communicate.”
Dr. Mancini also redesigned the call system using Toyota production models. Under the old system, residents had no continuity with the patients they admitted and discharged. The new system aligns the length of call shifts with patients' average length of stay (3.5 days), so that most patients are admitted and discharged by the same physician.
“It's been received well by interns because it allows them that role as primary care physician, to see patients from admission to discharge,” said Dr. Mancini.
As a physician leader balancing work with family responsibilities, Dr. Mancini serves as a role model for younger physicians on how to prevent burnout. She was married during her first year as faculty at Denver Health in 2007 and now has two preschool-age children.
“Physicians are often afraid to ask for help or to appear weak,” she said. “But if we teach them good coping mechanisms and good communication while they're young and in training, they'll have that skill set when they're older” and trying to balance work with family.
Dr. Mancini and her husband often invite residents to their home for dinner parties, graduations and other occasions, and she meets with each resident individually twice a year to discuss goals and concerns.
Her talent and commitment have led to several prestigious teaching awards, including the Excellence in Education and Leadership in Education award, for which she was nominated by medical students and residents, and Denver Health's Outstanding Educator Award.
“She has become known as the top mentor within our program, and devotes a significant amount of time and effort to ensuring resident wellness,” said Dr. Schwartz. “Personally, I have learned more from Dr. Mancini than any other attending with whom I've worked.”.
Diagnostic acumen and efficiency
Jensa Morris, MD
Medical School: Mount Sinai School of Medicine, New York City
Residency: Brigham and Women's Hospital, Boston
Title: Hospitalist, Yale-New Haven Hospital, New Haven, Conn.
Jensa Morris, MD, gets a kick out of the amazed look on interns' faces when she comes up with a correct diagnosis only minutes after entering a patient's room.
“They think I have magical powers,” said Dr. Morris. “But unbeknownst to them, I have already talked to the primary care physician and consultants, and that helps me know the patient.”
Tracking down details, communicating and listening are essential to solving complex medical cases, said Dr. Morris, who is highly respected at Yale-New Haven for her diagnostic skills. “I love going back and gathering data and reviewing all the records, talking to all prior physicians, and listening to patients extensively.”
Spending so much time on each case may seem impractical, but Dr. Morris has proven just the opposite. In fact, said her supervisor and Top Docs nominator, she is one of the most efficient physicians in the hospital.
“Dr. Morris consistently has one of the lowest lengths of stay and one of the highest 11 a.m. discharge rates on the hospitalist service,” said Peter N. Herbert, MD, FACP, senior vice president of medical affairs and chief of staff. “In addition, her rate of discharge summaries performed within 24 hours of discharge is consistently 100%.”
Dr. Morris' approach is not only efficient but has led to significant improvements in quality of care, especially in the management of patients with hip fractures, added Dr. Herbert. Under her leadership, length of stay for hip fracture patients has been shortened by 1.4 days while readmissions have dropped by 20% and mortality has plunged an impressive 60%.
Dr. Morris herself was surprised by the encouraging statistics, because she hadn't been following any particular protocol aimed at improvement, just implementing evidence-based practices and paying attention to details. The key, she said, was being on the floor every day talking to patients, nurses and physicians, unlike a consultant who might only show up to deal with complications.
“By seeing patients every day I was able to easily recognize all the normal, expected changes postoperatively, such as hyponatremia or low platelets, which typically resolve themselves in couple of days,” she said. “In more complicated cases, I was able to prevent problems by paying attention to details such as medication reconciliation, volume status and talking to the family and primary care physician.”
Dr. Morris also helped improve adherence to evidence-based practices for managing hip fracture patients, including preoperative cardiac evaluation, beta-blocker utilization, deep venous thrombosis prophylaxis, and antimicrobial prophylaxis. She worked extensively with orthopedic staff on delirium prevention and incorporated mid-level practitioners into the care team.
Dr. Morris not only pays close attention to patients while they are in the hospital but also follows up with them at home. She is the only physician on staff who sends a follow-up card and note to every patient discharged from her care. She even gives patients her cell phone number with instructions to call her any time.
“People ask me if giving out my number is a problem, but it actually makes my life easier,” said Dr. Morris. “Being able to address a family's problem instantly, as soon as it arises, prevents so many problems down the road, and for most patients just having the number and knowing they can call if they need to reduces their anxiety.”
Similarly, taking time to communicate with primary care physicians at admission and discharge and at important points during a patient's stay also saves time, she said.
“If you speak to the primary care physician first, you don't have to repeat tests or diagnostic pathways that aren't relevant,” she said. “Any decision we make has to be in line with what the primary care physician would do, so talking to them helps me—and it's essential for care.”.
Getting involved is key to success
Viral S. Shah, MBBS, FACP
Medical School: B.J. Medical College, Ahmedabad, India
Residency: Henry Ford Hospital, Detroit
Title: Hospitalist, Tacoma General Hospital and Allenmore Hospital, MultiCare Health System, Tacoma, Wash.
Viral S. Shah, MBBS, FACP, isn't one to stand on the sidelines and complain about flaws in the system. A case in point: When he became concerned that his financial advisor may not be looking out for his best interests, he decided to help solve the problem by becoming a financial planner himself.
“While working full time as a hospitalist, I went to school and worked part time as a financial planner,” said Dr. Shah. After passing the financial planner board certification exam, he approached the retirement committee at MultiCare Health System with some ideas for cutting expenses that led to over $1 million in annual savings and access to lower-cost investment options for more than 9,000 employees.
Dr. Shah's foray into financial planning is emblematic of his approach to his career. Whether dealing with clinical matters, legislative issues or workplace improvements, he believes that personal involvement can effect widespread change.
“As a clinician I can impact one patient's life, but as a person who's in the quality or process improvement arenas, I can impact more than one patient's life,” said Dr. Shah, who started a Council of Young Physicians for ACP's Washington Chapter. “I enjoy being a coordinator because it ultimately impacts patient care.”
As a member of MultiCare's peer review committee, Dr. Shah coordinated the development of a better screening tool for moving cases forward.
“Prior to the implementation of this tool, the process involved subjective decision making,” he said. “I created a pathway so there would be an objective way that anyone could follow and decide whether a case merited a full review.”
Building on that pathway, Dr. Shah created a series of recommended actions depending on whether the standard of care had been met in various areas, such as clinical judgment or professionalism.
“What to do next is automatically there now,” he said. “We don't have to reinvent the wheel with each case, so it can become faster and more efficient.”
In the clinical quality arena, Dr. Shah is leading a system-wide initiative to reduce congestive heart failure rehospitalizations across three MultiCare hospitals. The program, which focuses on educating patients, making timely appointments after discharge, complying with core measures, and integrating palliative care, has so far had encouraging results, said Dr. Shah.
Between 2010 and 2012, the hospitals boosted overall compliance with three core measures: evaluation of left ventricle (LV) function (from 99.7% to 100%); angiotensin-converting-enzyme inhibitor and angiotensin II receptor blockers for patients with LV dysfunction (from 93.2% to 98%); and discharge instructions (from 80.7% to 91%).
As the internal medicine liaison with the Tacoma Family Medicine Residency Program, Dr. Shah focuses on the importance of developing a caring bedside manner rather than relying solely on computer records. He encourages residents to base their initial differential diagnosis purely on talking to and examining the patient.
“Most of the time there's a lot of information available in the electronic health record, but that can stunt critical thinking,” he said. “As we rush through our day, it's tempting to review the computer results and spend as little time as possible with the patient, but residency is our only opportunity to teach future physicians the importance of the human touch.”
For Dr. Shah, daily interaction with patients is essential because it allows him to see problems at the individual level that might require systemic solutions. For now, he sees himself staying involved on all fronts, from bedside rounding to quality improvement to political advocacy.
“Dr. Shah is an extremely energetic, self-motivated and constantly self-educating physician who has an unquenchable thirst to be involved in multiple different process improvement initiatives,” said David Chen, MD, FACP, medical director at MultiCare and a 2008 Top Hospitalist. “He's not satisfied to just do a good job, but has expanded his knowledge in various areas, including financial, legal, palliative care and substance abuse, in order to excel in his work.”.
Equal passions for teaching, QI
Kimberly M. Tartaglia, MD, FACP
Medical School: Rush Medical College, Chicago
Residency: University of Chicago
Title: Assistant professor of clinical medicine and pediatrics, Ohio State University Wexner Medical Center (OSUWMC), Columbus.
Kimberly M. Tartaglia, MD, FACP, considers teaching medical students how to conduct a thorough and efficient physical exam one of her major goals. But she also asks them to consider the evidence before leaping to diagnostic assumptions.
“Historically, medical students have been taught how to perform a comprehensive exam without thought to how specific exam findings can influence the differential diagnosis,” said Dr. Tartaglia, who serves as associate director for clinical curriculum for third- and fourth-year medical students at OSUWMC. “We want to introduce the concept of ‘evidence-based physical diagnosis' early in their training.”
A case in point is the diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE), she said. Traditionally, students were taught to look for Homan's sign, but evidence suggests that it is not a reliable predictor of DVT or PE. Instead, she teaches students to use the Wells criteria, a 10-point scoring system to calculate risk for DVT.
The evidence-based teaching strategy is part of the Lead Serve Inspire curriculum being rolled out this year at OSUWMC. Teaching focuses on applying clinical reasoning skills, along with quality improvement and cost-conscious care concepts, to actual patient care situations.
“Instead of just going through the motions of physical exam and learning diagnostic maneuvers that may or may not have any diagnostic implications,” said Dr. Tartaglia, “we teach the physical exam based on implications of particular findings and how that might help change their management of the patient.”
The Lead Serve Inspire curriculum matches perfectly with Dr. Tartaglia's interests in teaching and quality improvement. Two years ago, she introduced a quality improvement curriculum for fourth-year medical students that allows them to develop their own quality improvement projects.
As director of quality improvement operations for the entire hospital medicine division, Dr. Tartaglia tries to integrate student projects with department-wide quality initiatives.
For example, last year one team worked with the general medicine services and an infectious disease specialist to pilot an antibiotic timeout, a concept promoted by the Centers for Disease Control and Prevention that asks clinicians to stop and assess patients' use of antibiotics to ensure that the right medications are being used for the right indications. As a result of the medical students' preliminary work, the timeout concept has been implemented in OSUWMC's general medicine services and the ICU, with the hope that it will reduce overall use and associated costs.
Mentoring the honors students is one of the most rewarding parts of her job, said Dr. Tartaglia, who was named Mentor of the Year by the graduates of the class of 2012.
“Individual time is the most appreciated by the students,” said Dr. Tartaglia. “In the quality honors elective I get the opportunity to sit down with them one-on-one or in small groups and help them to identify what's most important in their careers.”
Perhaps most impressively, Dr. Tartaglia's achievements in teaching and quality improvement have occurred over only a few years into her first faculty position.
“Dr. Tartaglia is a natural leader, mentor and educator,” said Vineet M. Arora, MD, FACP, a hospitalist at the University of Chicago and a 2009 Top Hospitalist, who mentored Dr. Tartaglia during her residency and nominated her for Top Docs.
“Her dedication to improving the quality of care for her patients as well as educating future physicians on how to study and implement quality improvement programs has been recognized through several leadership positions and activities that she has accomplished already in four years as faculty at Ohio State University,” Dr. Arora said..
Growing a small-town service
Douglas A. Towriss, MD, ACP Member
Medical School: Indiana University School of Medicine, Indianapolis
Residency: Indiana University
Title: Chief medical officer and director, Hospital Medicine Associates, Schneck Medical Center, Seymour, Ind.
As chair of the peer review committee at Schneck Medical Center, Douglas A. Towriss, MD, ACP Member, was troubled by the idea of singling out poor performers. So instead of reprimanding physicians with the highest sepsis mortality rates, he embarked on a hospital-wide educational campaign aimed at bringing everyone up to speed on evidence-based practices.
“We educated the emergency department, nurses, and medical staff on the importance of early goal-directed therapy, recognition of sepsis, and management in the first four hours to resuscitate a patient,” said Dr. Towriss. “As a result, we had a significant drop in mortality.”
The success of the sepsis campaign led to other quality improvement initiatives at the 113-bed community hospital, such as a current push to eliminate the indiscriminate use of Foley catheters to reduce catheter-associated infections. Education has proven to be a much more effective tool than punishment in reversing negative trends, Dr. Towriss said.
“In general, we found that people aren't alone when they struggle with managing particular illnesses,” he added. “It really helps, as a group, to discuss the application of evidence-based guidelines in a meaningful way.”
Dr. Towriss' inclusive leadership style has served him well in the small community of Seymour, Ind., where community physicians were initially skeptical about working with hospitalists. He moved to the town of 22,000, where his wife grew up, after residency, and established a private practice specializing in internal medicine and pediatrics.
“Within a year, several physicians asked me to see their patients who got critically ill, and my inpatient practice grew,” he said. To handle the increased demand for inpatient services, he teamed up with another solo internist, David Dollens, MD, FACP. In 2008, Grant J. Olsen, MD, ACP Member joined the group to establish a formal hospitalist program at Schneck Medical Center. Dr. Towriss was named the center's chief medical officer in 2011.
“We grew the hospitalist program from within, which was really necessary because in a small town people are very connected to their physicians,” he said. “We've built trust with a lot of the physicians in town and now they're glad we're here.”
Realizing that many local physicians were family practitioners taking care of both children and adults, Dr. Towriss also thought it important to offer pediatric hospitalist services. So he began to hire hospitalists who were double-boarded in internal medicine and pediatrics to provide 24-hour service to the whole spectrum of patients, from infants to the elderly. His group now includes four med-peds specialists and one internist.
Impressed by the hospitalist group's results with critically ill patients, hospital administrators soon asked Dr. Towriss to take over care of ventilated patients. But Dr. Towriss was concerned about causing resentment among the medical staff, so he created a ventilator certification program as part of the credentialing process that allowed qualifying nonhospitalist physicians to retain their ventilator privileges.
“After going through that program, several of the physicians rescinded their privileges for ventilator management and, by default, we became the only physicians running ventilators,” he said. Since the group took over ventilator management in 2008, the hospital's ventilator-associated pneumonia rate has plunged from 6% to zero.
Besides his clinical acumen, Dr. Towriss is known for his ability to connect with patients in difficult situations.
“One of the first things I try to do is develop an alliance and a rapport, because until the patient trusts me it's going to be challenging for them to tell me the things I need to know to make the right diagnosis,” he said. “I spend a lot of time on relationship building to make sure the patient is comfortable and the family is included and that they understand their diagnosis.”
That's time well spent when it becomes necessary to deliver unwelcome news, he said. “If you spend the time on the front end explaining things to the patient, it makes a big difference when you go back to tell them something that's hard to hear,” Dr. Towriss said.
“Dr. Towriss has tremendous clinical acuity and makes very keen and difficult diagnoses,” said Dr. Olsen, who nominated him as a Top Hospitalist. “More importantly, he explains the burden of the disease very effectively and compassionately to his patients.”.
A champion for palliative care
Kevin J. Whitford, MD, ACP Member
Medical School: University of Iowa College of Medicine, Iowa City
Residency: University of Kansas Medical Center, Kansas City
Title: Practice chair, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, Minn.
During the 1990s, Kevin J. Whitford, MD, ACP Member, developed an interest in hospice and palliative medicine when he cared for several hospice patients as part of his private practice in central Iowa. He loved that side of his practice, and he wondered why hospice care was often isolated from other inpatient services.
“I saw the value of having hospitalists with expertise in symptom management caring for suffering and dying patients,” said Dr. Whitford, who joined Mayo's hospitalist practice in 2000 and soon after became board certified in palliative care.
In 2003, Dr. Whitford was part of the team as Mayo launched a comprehensive palliative care consult service spanning two hospitals, in which patients are seen by multidisciplinary teams. Since its inception, the consult service has grown rapidly, said Dr. Whitford, from serving a total of 2,000 patients during its first five years to serving more than 2,000 this year alone.
“Dr. Whitford has worked diligently to educate all physicians within our organization about the benefit to patients of palliative care,” said David Klocke, MD, FACP, chair of the hospital medicine division. “He is a true master of his field, and commands the undying respect of his peers for his superb clinical judgment.”
Forging relationships with existing staff was the key to successfully integrating the palliative care program with the existing cancer care services, said Dr. Whitford.
“We were a new addition to the cancer care services practice, and if we did not integrate successfully with nursing, oncology, hematology, social work, pharmacy, therapy services and all of the other teams operating as a team there, we would fail,” he said. “We set up those services as close partners with nursing and we have built on that as we have incorporated a standardized rounding checklist and worked together to assure the highest quality and safest care.”
Dr. Whitford assumed a very hands-on role during the program's development, maintaining a constant presence on the unit and serving as the physician liaison for the nursing unit. His close involvement made him better able to perceive problems and come up with solutions, he said.
“I can only lead effectively if I work in the practice and understand how the systems work,” said Dr. Whitford. “I hope I make a more credible leader because I still spend the majority of my time caring for patients and working in our system.”
In addition to his clinical and leadership accomplishments, Dr. Whitford is an expert in documentation and coding and has helped Mayo meet national hospitalist benchmarks. Despite his many roles in the hospital, he's also found time to work towards a master's degree in clinical research.
“Dr. Whitford is a selfless and masterful clinician in all areas related to the hospital, whether it is clinical expertise, quality improvement, billing and coding, or patient satisfaction,” said Dr. Klocke, who nominated Dr. Whitford for Top Docs. “He gives tirelessly of his time and effort and is never too busy to help another colleague or see as many extra patients as necessary.”
Dr. Whitford's seemingly endless energy is rooted in his passion for patient care. His genuine commitment to the plight of those with life-threatening illnesses has made him “beloved by patients and all the members of his multidisciplinary team,” said Dr. Klocke.
Recent work with the local Somali immigrant population as well as medical mission trips to El Salvador and Haiti have increased his sensitivity to patients' problems, said Dr. Whitford. The more he learns about different cultures, he said, the more he tries to treat every patient as an individual.
“I try to be very careful to understand the individual in front of me, to understand their goals for care and their preferences,” he said. “You shouldn't make any assumptions because within any group of society there is significant variation about what people want and what's right for them.”.
A pioneering post-acute hospitalist
Jerome Wilborn, MD
Medical School: Washington University School of Medicine in St. Louis
Residency: University of Illinois, Chicago
Fellowship in pulmonary and critical care medicine: University of Michigan, Ann Arbor, Mich.
Title: National medical director, post-acute care services, IPC the Hospitalist Company, Ann Arbor, Mich. branch.
In the late 1990s, Jerome Wilborn, MD, was among the first to recognize the connection between high hospital readmission rates for frail elderly patients and the paucity of physician leadership in the post-acute care setting. After patients receive daily, specialized care in the hospital, he thought, it wasn't surprising that they deteriorated in skilled nursing facilities (SNFs) with little on-site physician care.
“In the hospital setting, they had everything, all the diagnostic and therapeutic armamentarium, and now all of a sudden they're being seen once or twice a month,” said Dr. Wilborn. “These folks are the sickest people in our health care continuum and you can't justify not taking care of them, and the only way to take care of them is to see them and treat them.”
Recognizing an unfilled niche in the market, Dr. Wilborn launched a post-acute care hospitalist service with the idea that a higher level of physician care within SNFs would result in lower hospital readmission rates and reduced costs. After a couple of failed startups, he developed a successful practice before merging in 2010 with IPC The Hospitalist Company.
Since merging with IPC, Dr. Wilborn has expanded his practice and reduced readmission rates for frail elderly patients. That's meaningful to Medicare, which recently launched an initiative to reduce avoidable hospitalizations among SNF residents based on research showing that about 70% of hospital readmissions could be avoided by improving care in nursing facilities.
“Perhaps more than any physician practicing today, Dr. Wilborn has vaulted the practice of hospital medicine into the arena of post-acute care, which has traditionally been a largely underserved market,” said ACP Member Adam D. Singer, MD, chair and chief executive officer of IPC and Dr. Wilborn's Top Docs nominator. “Dr. Wilborn has been building a post-acute hospitalist model which recognizes and responds to the needs for inpatient care with the same level of attention, urgency and discipline that it receives in acute care facilities.”
Dr. Wilborn is known as much for his tenacity as his innovation in the post-acute care arena. Once, frustrated that patients were being discharged to nursing facilities without physician input, he rode in the ambulance to make sure a patient got to a facility that was affiliated with her regular physician.
Realizing that “we needed a better mechanism to get patients to specific nursing homes,” he now hires nurses and social workers as care coordinators working with IPC physicians to discharge patients to IPC-staffed post-acute facilities. Buoyed by IPC's financial resources, Dr. Wilborn's group developed a software tool that allows care coordinators to track patients; communicate with families throughout the transition process from hospital to nursing facilities to home-based care; and keep accurate data on readmissions.
“The idea was that frail elderly patients are always in and out of different facilities, always moving during their last three to five years of life expectancy and you can't take care of these patients unless you know where they are,” Dr. Wilborn said. “Now we know where everyone goes once they come into our system, and where they're moved to.”
Dr. Wilborn's model has been so successful that he has almost doubled his staff of physicians from 23 to 45 since the practice joined IPC. During the same time, their patient visits have increased from 9,000 to 17,000 per month and the aggregate readmission rate from nursing facilities of recently hospitalized patients has plunged to under 5%, far below the national average of about 23%.
“What's really nice is that I know that this model is positively affecting lives,” said Dr. Wilborn. “We know readmissions are tied to mortality, so when we can take it to less than 5%, I know we're having an impact.”
The Top Docs profiles were written by Janet Colwell, a freelance writer in Miami.
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ACP Hospitalist Weekly
From the May 22, 2013 edition
- Warfarin better than heparin bridging during cardiac device surgery
- Intensive-dose statins don't confer greater diabetes risk for post-MI elderly than moderate doses
Cartoon Caption Contest
This issue's winning cartoon caption was submitted by Jennifer L. Norris, MD, ACP Member. Thanks to all who voted!
"I had something else in mind when I asked for an outline of the patient's condition."
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