The inpatient wards and the outpatient clinic are part of the same hospital where I work, but they are like different planets.

On the inpatient side, the patients are acutely ill — malignant brain tumor, acute renal failure, heart valve infections, intestinal bleeding, gravely low platelet levels, sudden-onset delirium, metastatic esophageal cancer, severe aortic valve stenosis, disseminated blood infection, liver failure, intractable seizures. Whenever I’ve started a month on the inpatient ward, I would always blanch the first time I’d look at my list of patients. After months in the clinic, I’d always forget how sick these patients could be.

Not so in the outpatient clinic, where patients get their regular medical care to manage everyday chronic illnesses like diabetes, hypertension, obesity and heart disease. The prosaic nature of these diseases by no means suggests that outpatient medicine is calm. It’s quite the opposite, in fact — a nonstop frenetic pace of too much to do in too little time. But it’s comforting to know that there is a low likelihood that your patients will drop dead on the spot.

Traditionally, internists practiced both outpatient and inpatient medicine. In fact, this distinction was never even made: Doctors took care of you when you came to the office and took care of you when you were admitted to the hospital. In some ways, this model is the ideal — your doctor was your doctor, no matter where you were or how sick you were.

I tried this for a short time early in my career, working in a private practice office while also taking responsibility for the patients admitted to the hospital. But medicine had ballooned into a round-the-clock, high-tech affair in the years since Marcus Welby, and the two sides of medicine were nearly impossible to balance..

I would get up at the crack of dawn to round on the hospitalized patients, then rush to the office for a full slate of scheduled patients. Throughout the day, I’d field calls from the nurses in the hospital: Someone’s potassium was low. A patient had new symptoms of nausea. A feeding tube was clogged. The M.R.I. results were back. Dialysis was canceled.

It was the worst feeling in the world, trying to focus on patients in the office while managing my hospitalized patients by phone until I could finish up, then racing back to the hospital for evening rounds. I knew I was doing a substandard job with both sets of patients, but I couldn’t be in two places at once. This was simply unsustainable.

This turned out to be the general conclusion of the larger medical community. Prodded by efficiency pressures from managed care and the reality that most internists couldn’t feasibly do inpatient and outpatient medicine at the same time, the “hospitalist” subspecialty was created — doctors who would work full time on the inpatient side, caring for hospitalized patients on the minute-to-minute basis that they require, ideally staying fully in touch with the patient’s primary care doctor.

For better or worse, the last 15 years have solidified this model. There are now some 30,000 hospitalists, not to mention a professional hospitalist society, specialized journals and academic meetings.

There are many critics of the new model, rightly pointing out that it fragments care even more. But having practiced on both sides of the divide, I think that it is impossible to return to the old-style doc who does everything. Each job is all-consuming, and the patients require full energy and focus. There really isn’t any way to do both well.

The medical center where I work moved toward this model a decade ago. Over all, it works reasonably well, though inpatient-outpatient communication has yet to reach the ideal. But if one of my own patients is hospitalized while I’m at clinic, I can breathe a sigh of relief that she will be cared for by one of my colleagues who is present, full time, on the ward.

The net effect is that the inpatient and outpatient care of our patients is shared among a group of physicians who, ideally, all know and trust one another. It’s not a perfect system by any means, but among the imperfect choices out there, it is probably the best.

Despite my years doing this, I still cringe when someone calls me a “hospitalist” while I’m on the ward. It sounds like I am taking care of hospitals rather than patients. (But I’ve already given my two cents about this.)

There are moments when I pine for the simpler days (if they ever actually existed), when patients could get everything they needed from one doctor. But that era no doubt had as many flaws as strengths. As I rummage around in my pockets, trying to remember whether I’ve left my stethoscope on the inpatient ward or back in clinic, I accept that we can’t choose the era in which we practice medicine, so we may as well make the best of what we have.

Danielle Ofri is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is “Medicine in Translation: Journeys With My Patients.”

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By Erin Steele, Record-Gazette

Posted 1 day ago

There is an outbreak of Forest Tent Caterpillar in the Peace River area – visible by patches of trees void of green on Misery Mountain and throughout the valley – and caterpillar populations are set to increase over the next few years.

According to Mike Maximchuk, a forest health officer with Environment and Sustainable Resource Development (ESRD), this particular species will periodically outbreak, for a yet-unknown reason every seven to 10 years across Northern Alberta.

The last outbreak in Peace River, according to Maximchuk, ended in 1996.

“The Peace River area has been overdue for a forest tent caterpillar outbreak for quite some time,” he told the Record-Gazette by phone.

Typically an outbreak in any given area lasts between four and seven years, with the caterpillar population growing so exponentially that anything that could potentially downsize the population is deemed futile.

“All the parasites and predators and birds and so forth just can’t keep up with the reproductive capacity of the tent caterpillar. They just can’t control the populations,” Maximchuk said.

Now that they have arrived, the only thing that could potentially downsize populations in the first few years of an outbreak is if we get a late spring frost or snowfall, he added.

“And as they get bigger, they eat more and more leaves and so the pattern of defoliation becomes much greater, much faster. And they’ll still be feeding for probably at least two more weeks before the majority of them have finished feeding and turn into a pupae,” Maximchuk says.

The Forest Tent Caterpillar has hormones in its body that triggers when it has finished feeding. At this point they spin themselves a silk cocoon surrounded by yellow powder – ten days later the pupae hatches and turns into a brown moth, either male or female.

These moths’ sole purpose is to mate. They will lay eggs around the tips of branches and tops of trees, and there they will remain until next spring when they hatch as caterpillars.

According to Maximchuk, the caterpillars and their effect of defoliation will migrate across the landscape.

“It might move 30, 40 kilometres in a given year, sometimes more. And as they’re building more and more survive so population spreads into more and more areas as they move and as they grow,” Maximchuk said.

The caterpillars are expected to reach the pupae stage around the end of June, beginning July, with Peace River residents expected to see the unusually large amount of moths shortly after this time.

“Those brown moths will be attracted to lights on buildings, on people’s houses, on gas stations, on the grocery stores,” Maximchuk said.

The affected trees will re-grow a secondary set of leaves a couple weeks following the last of the caterpillar’s feeding to help them maintain their existence, though aesthetically it will not mirror the shade visible a few weeks ago, Maximchuk says, as the leaves of the second set are smaller.

Though the caterpillar species does not directly kill trees on its own, it does weaken them which makes the trees less resilient to other insects and diseases.

Forest Tent Caterpillars are found naturally in the forest, but usually in such low numbers they go unnoticed.

“And then something triggers their populations to increase exponentially. No one is really sure exactly what triggers it. It could be favorable weather conditions,” Maximchuk said.

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Children's Hospital of Philadelphia

Dr. Rebecca Ruebner from the Children's Hospital of Philadelphia presents research on kidney disease in young patients

Rebecca Ruebner, M.D., who cares for patients with kidney disorders at The Children's Hospital of Philadelphia, received a Young Investigator Award of the American Transplant Congress (ATC) at its national meeting this week in Boston.

Dr. Ruebner, a fellow in the Division of Nephrology at The Children's Hospital of Philadelphia, received the award in recognition of research she presented June 5 at the ATC, entitled, "Risk Factors for End-Stage Kidney Disease after Pediatric Liver Transplantation."

In this study, a retrospective analysis of outcomes after all pediatric liver transplantations performed in the U.S. from 1990 through 2010, Dr. Ruebner found that end-stage kidney disease was relatively uncommon in these children, occurring in 167, or 2 percent, of the 8,976 patients who received liver transplants.

"This rate of end-stage kidney disease in children is considerably lower than that found in adults who received liver transplantation," said Dr. Ruebner, "but children who do develop end-stage kidney disease have a high mortality rate." She added that in all patients who receive liver transplants, the immunosuppressive drugs they must take to prevent their bodies from rejecting the donor liver carry a risk of kidney damage.

Dr. Ruebner said the study reinforces the importance of closely following children for the first signs of kidney disease after they receive a liver transplant. The Nephrology program at The Children's Hospital of Philadelphia was again ranked in the top two pediatric programs in the nation by U.S. News & World Report's 2012-13 survey of Best Children's Hospitals, announced this week.

About The Children's Hospital of Philadelphia: The Children's Hospital of Philadelphia was founded in 1855 as the nation's first pediatric hospital. Through its long-standing commitment to providing exceptional patient care, training new generations of pediatric healthcare professionals and pioneering major research initiatives, Children's Hospital has fostered many discoveries that have benefited children worldwide. Its pediatric research program is among the largest in the country, ranking third in National Institutes of Health funding. In addition, its unique family-centered care and public service programs have brought the 516-bed hospital recognition as a leading advocate for children and adolescents. For more information, visit http://www.chop.edu.

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NASHVILLE, Tenn. – Health IT Services Group (HITSG) announces the acquisition of the eRenalMD practice management system, which will be integrated with the Acumen nEHR clinical tool. Acumen PM, when used in conjunction with Acumen nEHR, will offer nephrologists a fully-integrated, web-based platform to manage all of the clinical and financial aspects of their business, and will provide them the tools to help satisfy the requirements of the Centers for Medicare & Medicaid Services’ Electronic Health Records (CMS EHR) Incentive Program, commonly known as “Meaningful Use.”

Acumen nEHR currently provides nephrology practices with a real-time dashboard for clinical data and patient information, and also provides the technology to allow physicians, through their use of such technology, to demonstrate and meet the standards for Meaningful Use. Acumen PM will offer nephrologists an easy-to-use, integrated platform to manage administration, billing, accounts receivable, as well as revenue and receivables reporting.

“The addition of Acumen PM truly differentiates us from other platforms, and we’re excited to now offer nephrologists a complete system to help streamline the day-to-day operation of their practice and help fulfill Meaningful Use objectives,” said Dana Hensley, president of Health IT Services Group. “We hope to continue our success by providing our customers with a complete, robust system for nephrology with enhanced features for MCP and CKD billing needs.”

“We have an unparalleled expertise in nephrology Meaningful Use, and are excited to be able to add nephrology focus and expertise to the practice management environment,” said Hensley.

“Our practice management system was developed by nephrologists for nephrologists, and easily accommodates the workflows and processes that make nephrology such a unique specialty,” said Eric Maaske, president and CEO of eRenalMD, LLC. “We believe that this new, fully-integrated solution will quickly become the preferred choice for nephrology practices everywhere.”

For more information regarding Acumen’s new tools and platform, please visit www.AcumenEHR.com.

About HITSG

HITSG was formed to develop and deliver intuitive software tools to assist nephrologists in the practice of medicine. The Acumen solution was designed by nephrologists and made available under an internet-based service model. In December 2010, Acumen nEHR, version 6.0, was 2011/2012 ONC-ATCB Certified for meaningful use and is a CCHIT Certified® 2011 Ambulatory EHR. In addition to receiving these prestigious industry certifications, the Acumen nEHR product received a five-star usability rating from CMS, the highest possible score that can be achieved. HITSG partners with nephrology dialysis organizations and systems, hospitals, vascular access centers, laboratory systems, HIEs, and practice management systems to drive workflow and effectively streamline access, storage, and distribution of patient treatment information. HITSG, based in Brentwood, Tenn., is a wholly owned subsidiary of Fresenius Medical Care North America. More information regarding Acumen and Health IT Services Group can be found at www.AcumenEHR.com.

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