The Principles and Practice of Hospital Medicine reflects the
evolution of the specialty of Hospital Medicine at a time of increasing
pressures to address the ills of our health care system and to provide
quality patient care that is safe, effective, patient-centered, timely,
efficient, and equitable—the six dimensions defined by the Institute
of Medicine. Regardless of practice setting, all clinicians will be
increasingly called upon to improve the care they provide for populations of
patients. This requires optimizing the function of the entire health care
team, structuring their programs to better meet demand, and aligning their
performance measures with those of their hospital networks.
The first major part of this book, Systems of Care,
introduces key issues in Hospital Medicine, patient safety, quality
improvement, leadership and practice management, professionalism and medical
ethics, medical legal issues and risk management, teaching and development.
In general, most physicians have little formal training relating to complex
hospital systems or human error. These sections provide a background for
improving the hospital setting for patients through system redesign,
training, and teamwork.
The second major part of
this book, Medical Consultation and Co-Management, reviews core tenets of
medical consultation, preoperative assessment, and management of
post-operative medical problems. Although hospitalists have already changed
the health care system by their presence and up to 85% of hospitalists
report that they co-manage surgical patients, most do not have a surgical
background. Surgeons present key concepts relating to General Surgery,
Neurosurgery, and Orthopedic and Bariatric surgery, and anesthesiologists
cover key concepts of Anesthesia. Experts in anticoagulation from McMaster
University, Canada, review perioperative anti-thrombotic management and
prevention. These sections present a framework for improving the
co-management of surgical patients with significant medical illnesses that
make them vulnerable to post-operative complications.
The third major part, Clinical Problem-Solving in Hospital Medicine,
introduces principles of evidence-based medicine, quality of evidence,
interpretation of diagnostic tests, systemic reviews and meta-analysis, and
knowledge translations to clinical practice. Each field of medicine
challenges clinicians to recommend a course of action for a specific patient
at a particular time. To efficiently and safely obtain the right information
through examination and testing, physicians need to ask the right questions.
Increasingly, physicians must process an enormous amount of data in the care
of a single patient and do not have time to critically review the medical
literature at each encounter. The purpose of these chapters is to provide a
context for evidence-based medicine so that clinicians optimize how they
access information tools that facilitate clinical decision-making at the
point of care.
The fourth major part, Approach to
the Patient at the Bedside, covers the diagnosis, testing, and initial
management of common complaints that may either precipitate admission or
arise during hospitalization. Hospitalized patients differ from their
outpatient counterparts in many respects, including severity of primary
systemic illness precipitating admission, multiple co-morbidities that do
not fit into one subspecialty, the number and route of administration of
prescription drugs, and vulnerability to hospital-acquired complications.
Condensed accounts of patient cases presented in these chapters and
throughout the book provide examples of asking questions, thinking
critically, and diagnosing and assessing problems so that the reader may
apply key concepts directly to patient care. As much as possible this
approach offers evidence-based strategies that can be employed when
clinicians encounter an unfamiliar patient who has developed a new problem
that requires urgent evaluation.
The fifth major
part, Hospitalist Skills, covers the interpretation of common “low
tech” tests that are routinely accessible on admission, how to
optimize the use of radiology services, and the standardization of the
execution of procedures routinely performed by some hospitalists. Diagnostic
testing is rarely without risk or financial cost and almost never completely
accurate. The pursuit of diagnostic tests may also delay much needed
treatment; thus, physicians cannot pursue every diagnostic avenue, even if
patients want all the information. These sections review the process of how
to incorporate simple test results into clinical decision-making, how to
select imaging tests, and how to safely perform procedures.
The sixth major part, Clinical Conditions, reflects the
expanding scope of Hospital Medicine by including sections of Emergency
Medicine, Critical Care, Geriatrics, Neurology, Palliative Care, Pregnancy,
Psychiatry and Addiction, and Wartime Medicine. Although there have been
tremendous strides in the technology relating to the management of many
diseases and in proven therapies, performance gaps still remain. The
objective of this part of the book is to present current best practices and
highlight opportunities for improvement.
overarching goal of this first edition is to make available a comprehensive
resource for trainees, junior and senior clinicians, and other professionals
so that they can effectively work together to create opportunities to ensure
the delivery of high-quality health care and value.
Sylvia C. McKean, MD, SFHM, FACP