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Biomedical subjects

Robert M Wachter

Publications and source records attributed to Robert M Wachter.

At least 19 recordsLinked to original sources
PubMed2006

The expanding role of hospitalists in the United States.

Hospitalists are the most rapidly growing group of providers in the United States; in a few years, there will be more hospitalists than cardiologists in the U.S. While early growth in the field was driven by financial demands on hospitals, more recent incentives include a growing focus on improving the quality and safety of care. With current evidence suggesting both financial and educational benefits from the increased presence of hospitalists in both teaching and non-teaching settings, the environment is ripe for further expansion. Hospitalists are likely to embrace a number of additional clinical and non-clinical roles in the coming years. They will serve as change agents, hospital leaders and experts in both quality improvement activities and research initiatives around improving inpatient care delivery. As their skills sets and unique competencies become more clearly outlined, the next step will likely be the development of an independent specialty with its own board certification.

Burnout, Professional↗
PubMed2006

Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements.

BACKGROUND: The health care marketplace has changed substantially since the last assessment of demand for internal medicine physicians in 1996. METHODS: We reviewed internal medicine employment advertisements published in 4 major medical journals between 1996 and 2004. The number of positions, specialty, and other practice characteristics (e.g., location) were collected from each advertisement. RESULTS: Four thousand two hundred twenty-four advertisements posted 4,992 positions. Of these positions, jobs in the Northeast (31% of positions) or single specialty groups (36.8% of positions) were most common. The relative proportion of advertisements for nephrologists declined (P < .001), while the relative proportions of advertisements for critical care specialists (0.5% in 1996 to 1.7% in 2004, P = .004) and hospitalists (1.0% in 1996 to 12.1% in 2004, P < .001) increased. Advertisements for outpatient-based generalist positions (i.e., Primary Care and Internal Medicine) declined (-2.7% relative annual change, 95% confidence interval [95% CI] -4.1%, -1.2%) between 1996 and 2004, a decrease largely due to a substantial decline in advertisements noted between 1996 and 1998. However, over the entire time period, the combined proportion of advertisements for all generalists (hospitalists and outpatient-based generalists) did not change (0.5% relative annual change, 95% CI -0.8% to 2.0%). CONCLUSIONS: Since 1996, demand for the majority of medical subspecialties has remained constant while relative demand has decreased for primary care and increased for hospitalists and critical care. Increase in demand for generalist-trained hospitalists appears to have offset falling demand for outpatient generalists.

Advertising↗
PubMed2006

Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.

BACKGROUND: Restrictions in the hours residents can be on duty have resulted in increased sign-outs, that is, transfer of patient care information and responsibility from one physician to a cross-coverage physician, leading to discontinuity in patient care. This sign-out process, which occurs primarily in the inpatient setting, traditionally has been informal, unstructured, and idiosyncratic. Although studies show that discontinuity may be harmful to patients, this is little data to assist residency programs in redesigning systems to improve sign-out and manage the discontinuity. PURPOSE: This article reviews the relevant medical literature, current practices in non-health professions in managing discontinuity, and summarizes the existing practice and experiences at 3 academic internal medicine hospitalist-based programs. CONCLUSIONS: We provide recommendations and strategies for best practices to design safe and effective sign-out systems for residents that may also be useful to hospitalists working in academic and community settings.

Academic Medical Centers↗
PubMed2006

Reflections: the hospitalist movement a decade later.

August 2006 marks the 10th anniversary of the publication of an article in the New England Journal of Medicine in which Lee Goldman and I coined the term hospitalist-an event that many people characterize as the start of the hospitalist movement in the United States. The present article describes the history of those early days, highlighting some of the choices the field's initial leaders made to nurture the new specialty. In retrospect, although there were many examples of fortunate serendipity, there were also several key strategic choices, including the focus on gathering research data to demonstrate the value of the field to external stakeholders; the forceful rejection of mandatory hospitalist systems, particularly those promoted by managed care organizations; and the purposeful linking of our new field to the burgeoning movements to improve quality and patient safety in hospitals. Most of all, the field's spectacular growth and successes can be attributed to the daily work of thousands of hospitalists in clinical care, education, research, and systems improvement. These individuals have given life to our theoretical notion a decade ago that a new model for inpatient care would improve the American health care system and the care of inpatients.

Delivery of Health Care↗
PubMed2006

The 100,000 Lives Campaign: A scientific and policy review.

BACKGROUND: On June 14, 2006, the Institute for Healthcare Improvement (IHI) announced that its campaign to save 100,000 lives had far surpassed its goal--by saving 122,300 lives. THE INTERVENTIONS: Although many of the campaign's six "evidence-based practices" are supported by relatively strong evidence, the use of rapid response teams (the only intervention not already required or promoted by a major federal or Joint Commission initiative) is not. THE "LIVES SAVED": Secular trends could account for many of the "lives saved," which IHI acknowledges (and could have adjusted for, resulting in a markedly lower "lives saved" estimate). Moreover, IHI's estimates of lives saved are dependent on the case-mix adjustment-accounting for nearly three out of four "lives saved." The actual mortality data were supplied without audit by the more than 3,000 participating hospitals, and 14% of the hospitals submitted no data at all. POLICY IMPLICATIONS: IHI established and promoted a set of achievable goals for American hospitals and generated unprecedented amounts of social pressure for hospitals to participate. This remarkable achievement should be studied by other organizations seeking to generate widespread change in the health care field. CONCLUSIONS: Although the 100,000 Lives Campaign succeeded in catalyzing efforts to improve safety and quality in American hospitals, the promotion of rapid response teams as a national standard is problematic, and methodologic concerns regarding the "lives saved" calculations make it difficult to interpret the campaign's true accomplishments.

Academies and Institutes↗
PubMed2006

Impact of reduced duty hours on residents' educational satisfaction at the University of California, San Francisco.

PURPOSE: To assess the impact of the Accreditation Council for Graduate Medical Education duty-hour limitations on residents' educational satisfaction. METHOD: In 2003, the authors surveyed 164 internal medicine residents at three clinical training sites affiliated with the University of California, San Francisco, after system changes were introduced to reduce duty hours. On a questionnaire that used various rating scales, residents reported the value of educational activities, frequency of administrative tasks interfering with education, and educational satisfaction after duty hours were reduced. The authors compared univariate statistics and developed multivariable models to discern the relationship between hours worked and educational outcomes. RESULTS: In all, 125 residents (76%) responded. Residents rated the educational activities, morning report, and teaching others most highly. Answering pages and tasks related to scheduling were the most frequent barriers to educational activities. Residents reported that time spent in administrative activities did not change after duty-hour restrictions, and 68% said that decreased duty hours had no impact or a negative impact on education. In multivariable models, postgraduate year (PGY)-1 residents (p = .004), residents who reported feeling overwhelmed at work (p < .0001), and residents who reported working more than 80 hours per week (p < .05) had lower work satisfaction. However, only PGY-1 residents (p < .05) and those who felt overwhelmed with work (p = .01) were less satisfied with their education. CONCLUSIONS: In this residency program, duty-hour reduction did not improve educational satisfaction. Educational satisfaction may be more a function of workload than hours worked; therefore, systematic changes to residents' work-life may be necessary to improve educational satisfaction.

Academic Medical Centers↗
PubMed2006

Effect of the inpatient general medicine rotation on student pursuit of a generalist career.

BACKGROUND: Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain. OBJECTIVE: To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM. DESIGN: Multicenter cohort study. PARTICIPANTS: Third-year medical students between July 2001 and June 2003. MEASUREMENTS: End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of "Very Likely" or "Certain" to the question "How likely are you to pursue a career in GIM?"; and (2) entry into an internal medicine residency using institutional match data. RESULTS: Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01). CONCLUSIONS: Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.

Career Choice↗
PubMed2004

Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations.

BACKGROUND: Hospitalists are increasingly serving as inpatient attendings at teaching hospitals. The educational impact of this new model is unclear. We evaluated the relationship between type of attending (hospitalist vs traditional) and trainees' ratings of attending teaching and the overall ward rotation. METHODS: We analyzed data from a Web-based evaluation system containing all house staff and student evaluations of their attendings and internal medicine ward rotations at 2 university-affiliated teaching hospitals over a 2-year period (1999-2001). RESULTS: The overall evaluation completion rate was 91% (1587 of 1742 evaluations) by trainees working with 17 hospitalists and 52 traditional attendings. Trainees reported significantly more overall satisfaction with hospitalists than traditional attendings (8.3 vs 8.0 on a 9-point scale; P<.001) and rated hospitalists' overall teaching effectiveness as superior (4.8 vs 4.5 on a 5-point scale; P<.001). Perceived overall educational value of rotations was higher with hospitalist attendings (3.9 vs 3.7 on a 5-point scale; P =.04). Trainees evaluated hospitalists' knowledge, teaching, and feedback as superior to that of traditional attendings. There were no significant differences in reports of attendings' interest in teaching or patients, availability, or emphasis on cost-effectiveness. CONCLUSIONS: Trainees reported more effective teaching and more satisfying inpatient rotations when supervised by hospitalists. This analysis suggests that hospitalists may possess or accrue a specific inpatient knowledge base and teaching skill that distinguishes them from nonhospitalists.

Attitude of Health Personnel↗
PubMed2004

Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial.

BACKGROUND: Hospitalists are assuming an increasing role in the care of surgical patients, but the impact of this model of care on postoperative outcomes is unknown. OBJECTIVE: To determine the impact of providing a collaborative, hospitalist-led model of care on postoperative outcomes and costs among patients having hip or knee arthroplasty. DESIGN: Randomized, controlled trial. SETTING: Academic medical center. PARTICIPANTS: 526 patients having elective orthopedic surgery who are at elevated risk for postoperative morbidity. MEASUREMENTS: Length of stay, inpatient postoperative medical complications, health care provider satisfaction, and inpatient costs. INTERVENTIONS: A comanagement medical Hospitalist-Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation. RESULTS: More patients in the hospitalist group were discharged from the hospital with no complications (61.6% vs. 49.8%; difference, 11.8 percentage points [95% CI, 2.8 to 20.7 percentage points]). Fewer minor complications were observed among hospitalist patients (30.2% vs. 44.3%; difference, -14.1 percentage points [CI, -22.7 to -5.3 percentage points]). Observed length of stay was not statistically different between treatment groups. However, when adjusted for discharge delays, mean length of stay for patients in the hospitalist model of care was shorter (5.1 days vs. 5.6 days; difference, -0.5 day [CI, -0.8 to -0.1 day]). Total costs did not differ between groups. Orthopedic surgeons and nurses preferred the hospitalist model. LIMITATIONS: Care providers and patients were aware of intervention assignments, and the study could not capture all costs associated with the hospitalist model. CONCLUSIONS: The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the comanagement hospitalist model. Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted.

Aged↗