Increasing clinical demands and a reduction in traditional teaching opportunities at academic medical centers threaten the ability of hospitalists to participate in their institution's educational mission. Hospitalists with teaching as part of their career focus benefit from faculty development or the creation of teaching activities to stimulate interest in academic medicine and overcome pre-existing barriers to education. Our large, multi-site hospital medicine division sought to engage hospitalists from various practice settings in educational opportunities to expand their skill sets as teachers. An Education Council introduced seven initiatives embedded with educator roles for faculty: clinicopathological conference, clinical vignette competition, Grand Rounds, peer observation of teaching, teaching competition, visiting professorship, and ward teacher workshop. Program opportunities generated directorships, faculty, and peer development roles. Multimodal assessment demonstrated increased attendance, evaluations, recognition, scholarship, and events over time. This innovative heptad of faculty educational opportunities within an academic hospital medicine program is feasible, effective, and scalable.

OBJECTIVES:Telemetry is frequently overused in hospitals. The goal of this study was to evaluate a telemetry protocol aimed at decreasing inappropriate telemetry utilization across four different hospitals within a large healthcare system by modifying the electronic telemetry order to incorporate the 2017 American Heart Association practice guidelines on the appropriate use of telemetry and using an electronic nursing screening task form to safely discontinue telemetry.METHODS:We performed a retrospective analysis of telemetry utilization before and after we implemented a protocol across four hospitals within a large healthcare system. We compared the average number of days of telemetry monitoring and hospital length of stay during the preintervention period with the 6-month postintervention period.RESULTS:There were a total of 23,774 encounters evaluated. There was a statistically and clinically significant 24% decrease in telemetry duration between pre- and postintervention time periods (P < 0.0001). The mean (standard error) telemetry duration was 4.11 (0.17) and 2.36 (0.13) days in pre- and postintervention periods, respectively.CONCLUSIONS:The results of our study demonstrate a statistically significant decrease in overall duration of telemetry monitoring by nearly 1.75 days across each of the four hospitals with the implementation of a multifaceted telemetry protocol that included hardwiring the American Heart Association practice guidelines into the electronic order and using a nursing-driven discontinuation protocol.

Before the coronavirus disease 2019 (COVID-19) pandemic, vaping-related illness was the prevailing public health concern. The incidence of vaping-related illnesses-mainly e-cigarette, or vaping, product use-associated lung injury (EVALI)-went from a peak in September 2019 to a low in February 2020, and the Centers for Disease Control and Prevention decided to discontinue the collection of EVALI case reports. Despite the decrease in EVALI with the arrival of COVID-19, EVALI should still be considered a differential diagnosis for people with COVID-19 for reasons outlined in this review. This narrative review describes vaping devices, summarizes the adverse health effects of vaping on the lungs and other systems, considers the potential interplay between vaping and COVID-19, and highlights gaps in knowledge about vaping that warrant further research.

Internists frequently care for patients who suffer from breathlessness in both the inpatient and the outpatient settings. Patients may experience chronic refractory breathlessness despite thorough evaluation and management of their underlying medical illnesses. Left unmanaged, chronic breathlessness is associated with worsened quality of life, more frequent visits to the emergency room, and decreased activity levels, as well as increased levels of depression and anxiety. This narrative review summarizes recent research on interventions for the relief of breathlessness, including both non-pharmacologic and pharmacologic options.

Pulmonary manifestations of inflammatory bowel disease are increasingly recognized in patients with ulcerative colitis and Crohn's disease. Most commonly, incidental abnormalities are noted on chest imaging or pulmonary function tests. Although clinically significant pulmonary disease is less common, it can carry significant morbidity for patients. We review the presenting symptoms, workup, and management for several of the more common forms of inflammatory bowel disease-related pulmonary disease. Increased awareness of the spectrum of extraintestinal inflammatory bowel disease will help providers more readily recognize this phenomenon in their own patients and more comprehensively address the protean sequelae of inflammatory bowel disease.

Journal of Hospital MedicineVolume 15, Issue 10 p. 622-624 Perspectives in Hospital Medicine Academic Hospital Medicine 2.0: If You Aren't Teaching Residents, Are You Still Academic? Carrie A Herzke MD, MBA, Corresponding Author Carrie A Herzke MD, MBA cherzke1@jhmi.edu Department of Medicine, Johns Hopkins University, Baltimore, MarylandCorresponding Author: Carrie Herzke, MD, MBA; Email: cherzke1@jhmi.edu; Telephone: (443) 287-3631.Search for more papers by this authorDaniel P Hunt MD, Daniel P Hunt MD Department of Medicine, Emory University, Atlanta, GeorgiaSearch for more papers by this authorDaniel J Brotman MD, Daniel J Brotman MD Department of Medicine, Johns Hopkins University, Baltimore, MarylandSearch for more papers by this author Carrie A Herzke MD, MBA, Corresponding Author Carrie A Herzke MD, MBA cherzke1@jhmi.edu Department of Medicine, Johns Hopkins University, Baltimore, MarylandCorresponding Author: Carrie Herzke, MD, MBA; Email: cherzke1@jhmi.edu; Telephone: (443) 287-3631.Search for more papers by this authorDaniel P Hunt MD, Daniel P Hunt MD Department of Medicine, Emory University, Atlanta, GeorgiaSearch for more papers by this authorDaniel J Brotman MD, Daniel J Brotman MD Department of Medicine, Johns Hopkins University, Baltimore, MarylandSearch for more papers by this author First published: 19 February 2020 https://doi.org/10.12788/jhm.3354Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume15, Issue10October 2020Pages 622-624 RelatedInformation

As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.

The Clinical TeacherVolume 17, Issue 1 p. 31-35 The Clinical Teacher's Toolbox Transforming traditional shadowing: engaging millennial learners through the active apprenticeship Daniel Restrepo, Corresponding Author Daniel Restrepo drestrepo1@mgh.harvard.edu Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USACorresponding author's contact details: Daniel Restrepo, 55 Fruit Street, Boston, MA 02114, USA. E-mail: drestrepo1@mgh.harvard.eduSearch for more papers by this authorDaniel Hunt, Daniel Hunt Emory University School of Medicine, Atlanta, Georgia, USASearch for more papers by this authorEli Miloslavsky, Eli Miloslavsky Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author Daniel Restrepo, Corresponding Author Daniel Restrepo drestrepo1@mgh.harvard.edu Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USACorresponding author's contact details: Daniel Restrepo, 55 Fruit Street, Boston, MA 02114, USA. E-mail: drestrepo1@mgh.harvard.eduSearch for more papers by this authorDaniel Hunt, Daniel Hunt Emory University School of Medicine, Atlanta, Georgia, USASearch for more papers by this authorEli Miloslavsky, Eli Miloslavsky Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this author First published: 22 November 2018 https://doi.org/10.1111/tct.12975Citations: 4 Funding: We certify that we have received no funding for the creation of this work and have no disclosure of other sources of funding that would conflict with the published work. Conflict of interest: We certify that we have no primary or secondary competing interests or conflicts of interest in submitting and publishing this work. Ethical approval: The submitted work does not contain human subjects research and is composed of review of the available literature and suggestions to improve clinical practice. The authors certify that there are no ethical conflicts that would preclude its publication. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume17, Issue1February 2020Pages 31-35 This article also appears in:Toolboxes, tools and faculty development reviews RelatedInformation

Cancer is the second leading cause of death in the United States, and the majority of hospital admissions of patients with cancer occur because of uncontrolled, urgent symptoms. In addition to complex physical presentations, these patients often manifest a number of complex emotional and psychological responses resulting in a unique set of healthcare needs and expectations. Inpatient generalists or hospitalists frequently serve as the primary providers of medical care for these patients. Formal training for nononcologists on effective communication strategies in managing patients with cancer in a hospital setting may not fully prepare generalists for challenging patient encounters, however. This review assists generalists in approaching emotionally charged encounters when caring for patients with cancer on the wards. We explore patient factors that negatively affect successful communication, some of which can be addressed through a multidisciplinary approach. In addition, we present a checklist of preventive strategies in addressing emotionally charged patient responses and offer a number of preventive and restorative management approaches for dealing with such encounters. We provide a practical framework for recognition and management of the psychosocial and emotional challenges in the care of hospitalized patients with cancer.

BACKGROUNDMedicine subspecialty consultation is becoming increasingly important in inpatient medicine.OBJECTIVEWe conducted a survey study in which we examined hospitalist practices and attitudes regarding medicine subspecialty consultation.DESIGN AND SETTINGThe survey instrument was developed by the authors based on prior literature and administered online anonymously to hospitalists at 4 academic medical centers in the United States.MEASUREMENTSThe survey evaluated 4 domains: (1) current consultation practices, (2) preferences regarding consultation, (3) barriers to and facilitating factors of effective consultation, and (4) a comparison between hospitalist–fellow and hospitalist–subspecialty attending interactions.RESULTSOne hundred twenty‐two of 261 hospitalists (46.7%) responded. The majority of hospitalists interacted with fellows during consultation. Of those, 90.9% reported that in‐person communication occurred during less than half of consultations, and 64.4% perceived pushback at least “sometimes” in their consult interactions. Participants viewed consultation as an important learning experience, preferred direct communication with the consulting service, and were interested in more teaching during consultation. The survey identified a number of barriers to and facilitating factors of an effective hospitalist–consultant interaction, which impacted both hospitalist learning and patient care. Hospitalists reported more positive experiences when interacting with subspecialty attendings compared to fellows with regard to multiple aspects of the consultation.CONCLUSIONThe hospitalist–consultant interaction is viewed as important for both hospitalist learning and patient care. Multiple barriers and facilitating factors impact the interaction, many of which are amenable to intervention.

BACKGROUND: Overuse of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily implemented intervention to promote rational laboratory use without compromising resident education or patient care.METHODS: The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring laboratory orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized " general medicine" was duplicated during 2 consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, Massachusetts. The primary outcome was the total number of commonly used laboratory tests per patient day during 2 months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient day, adverse events, and resident and nursing satisfaction.RESULTS: A total of 5392 patient days were captured. The intervention produced a 9% decrease in aggregate laboratory use (rate ratio, 0.91; P = .021; 95% confidence interval, 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm.CONCLUSIONS: A bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in laboratory use. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study. (C) 2016 Elsevier Inc. All rights reserved.

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. This icon represents the patient's case. Each paragraph that follows represents the discussant's thoughts.

1Department of Medicine, University of California, Los Angeles, Los Angeles, California; 2Department of Medicine, Emory University, Atlanta, Georgia; 3Department of Neurology, University of California, San Francisco, San Francisco, California; 4Department of Medicine, University of California, San Francisco, San Francisco, California; 5Department of Pediatrics, University of California, San Francisco, San Francisco, California.

Problem For most physicians, the period of official apprenticeship ends with the completion of residency or fellowship, yet the acquisition of expertise requires ongoing opportunities to practice a given skill and obtain structured feedback on one’s performance. Approach In July 2013, the authors developed a clinical coaching pilot program to provide early-career hospitalists with feedback from a senior clinical advisor (SCA) at Massachusetts General Hospital. A Hospital Medicine Unit–wide retreat was held to help design the SCA role and obtain faculty buy-in. Twelve SCAs were recruited from hospitalists with more than five years of experience; each served as a clinical coach to 28 early-career hospitalists during the pilot. Clinical narratives and programmatic surveys were collected from SCAs and early-career hospitalists. Outcomes Of 25 responding early-career hospitalists, 23 (92%) rated the SCA role as useful to very useful, 20 (80%) reported interactions with the SCA led to at least one change in their diagnostic approach, and 13 (52%) reported calling fewer subspecialty consults as a result of guidance from the SCA. In response to questions about professional development, 18 (72%) felt more comfortable as an independent physician following their interactions with the SCA, and 19 (76%) thought the interactions improved the quality of care they delivered. Next Steps To better understand the impact and generalizability of clinical coaching, a larger, longitudinal study is required to look at patient and provider outcomes in detail. Further refinement of the SCA role to meet faculty needs is needed and could include faculty development.

BACKGROUND:As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important.OBJECTIVE:To develop and validate a quantifiable definition of academic success for AHPs.METHODS:A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey.RESULTS:Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6-18 years) and mean size of 36 faculty (range, 18-95). The mean total grant funding/program was $4 million (range, $0-$15 million), with mean funding/FTE of $364,000 (range, $0-$1.4 million); both were significantly higher than the comparison sample. The majority of SCHOLAR faculty (82%) were junior, a lower percentage than the comparison sample. The mean number of research abstracts presented over 2 years was 10.8 (range, 9-23).DISCUSSION:Our approach effectively identified a subset of successful AHPs. Despite the relative maturity and large size of the programs in the SCHOLAR cohort, they were comprised of relatively few senior faculty members and varied widely in the quantity of funded research and scholarship. Journal of Hospital Medicine 2016;11:708-713. © 2016 Society of Hospital Medicine.

A 20-year-old man presented with fever and a pericardial effusion. Five weeks earlier, sore throat, fever, malaise, and myalgias had developed. Broad-spectrum antibiotic therapy was administered, without improvement. A diagnosis was made.

The perspective ‘‘No to Greed’’ by Terpening in this issue of the Southern Medical Journal provides an appraisal on the controversy surrounding the cost of sofosbuvir as a potentially curative treatment for hepatitis C virus (HCV). Sofosbuvir represents a substantial advance in the treatment of HCV. The drug is taken orally, is generally well tolerated, and in clinical trials results in ‘‘cure’’ of this chronic disease in a high percentage of patients. These advantages are already widely known by the public and physicians. HCV is contributing to increasing hospitalizations for chronic liver disease and will likely intensify unless effective treatment is broadly applied. The seemingly excessive cost of this drug has been emphasized in a number of commentaries both in the medical literature and the lay press. The $1000-per-pill cost also has attracted inquiries from members of Congress, because the total cost of treatment for a large population of patients with HCV threatens to overwhelm the healthcare system, including Medicaid. Terpening acknowledges recent cost-effectiveness analyses, but appropriately questions their validity and in fact, their motivation, because a number of authors of these analyses report funding from Gilead Sciences, the maker of sofosbuvir. A flurry of additional cost-effectiveness analyses appeared during the past 7 months and essentially concluded that the drug is cost-effective for the individual patient; however, estimates of the total price tag for the US population are staggering and Gilead Sciences is profiting handsomely from this drug while negotiating deals to provide the drug for a fraction of the cost in other parts of the world. Terpening concludes by urging physicians to simply say no to prescribing sofosbuvir as a way of protesting the exorbitant $1000-per-pill ($84,000 per treatment course) pricing of sofosbuvir. Is saying no to prescriptions for individual patients likely to be an effective strategy in addressing this situation? Assuming physicians agree to say no, how might that conversation with patients proceed? And, by saying no, what will be the effect on patients’ perceptions of their physician? It seems unlikely that individual patient conversations will have a substantial impact on drug pricing, but we need to start somewhere, instead of simply waiting for government, insurers, and national organizations to act. We need to become more comfortable discussing costs with patients as prices for both diagnostic studies and therapies escalate. We need to be sure both patients and physicians understand the cost of sofosbuvir. It is essential to understand the direct cost to patients through copays that may be in place under insurance plans. A number of insurers and health systems are adopting guidelines that would shepherd sofosbuvir toward patients with evidence of more advanced disease. Physician review of these types of guidelines with patients should be helpful in conversations about sofosbuvir. A component of the discussion should be to make it clear that additional medications are in the short-term pipeline, as outlined by Feeney and Chung. These new medications suggest that prices should fall as competitive drugs reach the market. Saying ‘‘no’’ to sofosbuvir may be perceived as representing the best interests of the insurer or government payor. These conversations will require time, honesty, and a willingness to listen. It is critical that physicians not be seen as unilaterally denying effective treatment to patients in need, simply to save a third party money. Patients should believe that we are sharing in treatment and value decisions and that we will remain their advocate. Terpening has provided an important call to action by physicians, who cannot stand idly by during an era when drug and testing costs threaten to overwhelm the US healthcare system. We should become proficient at conversations with patients about cost and value, and sofosbuvir is merely one harbinger of conversations to come.