Hospitalists lead, coordinate, and participate in initiatives to improve the identification and treatment of patients and families in need of palliative care. Yet we often lack the knowledge and skills necessary to provide outstanding palliative care; we may also lack the comfort level we need to take care of patients at that stage of illness.
Steve Pantilat, MD, SHM president and member of the SHM Education Committee, established the Palliative Care Task Force to identify and create opportunities to improve palliative care in the field of hospital medicine. The Palliative Care Task Force had its inaugural meeting in August. Led by founder Dr. Pantilat and Chad Whelan, MD, Palliative Care Task Force chair, the task force established the following goals:
- Promote palliative care as an important skill and activity for hospital medicine physicians and providers;
- Identify and create palliative-care-focused educational activities for hospital medicine physicians and other key stakeholders within hospital medicine;
- Advocate for the creation and or support of hospital-based palliative care services;
- Promote the use of best practices in palliative care; and
- Develop a core community of hospital medicine physicians dedicated to improving our understanding of palliative care.
Our current task force membership is small but energetic. We actively recruit members, particularly nonphysicians and non-SHM members. Palliative care is a multidisciplinary field, and we hope the Palliative Care Task Force membership will reflect this diversity. Potential areas of growth include pharmacists, nurses, social workers, spiritual care providers, and nonhospitalist physicians. We are also looking for a pediatrician with an interest in palliative care to represent the pediatric interests among SHM members.
Since the first meeting in August our members have been developing a plan to achieve our identified goals. While the plan is still early in its development, we have designed a multimodal approach that will rely on traditional CME meetings, print media, as well as electronic media.
The task force’s short-term goals include promoting best practices in palliative care via SHM communication vehicles. For example, we plan to propose a series of articles for the forthcoming Journal of Hospital Medicine to highlight key issues in palliative care.
The 2006 SHM Annual Meeting will feature two workshops with a palliative care focus. One workshop will discuss how to build the case for a palliative care service; the other will address issues in pain management for hospitalized patients. We will learn from the 2006 experience as we look toward the 2007 SHM Annual Meeting in Texas. An electronic CME module is also under development.
Finally, we are planning an electronic compendium of resources and tools for practicing high-quality palliative care. Although the format has not been finalized, the concept is to provide resources that will make caring for palliative care patients as easy as possible.
While we are pleased with the progress of the task force to date, there is still much to do. Hospital medicine physicians can and should serve as leaders to improve palliative care. Traditional medical training focuses our efforts and thoughts of curing and preventing. We’ve all felt the exhilaration of making a life-saving diagnosis on the young, otherwise healthy patient; however, just as there are times to look for a cure at all costs, there are also times when we must treat our patients’ symptoms at all costs.
Often traditional medical training doesn’t provide us with the tools we need to best care for our patients and their families when palliative care goals become the priority. We hope this task force will raise the visibility of palliative care within SHM and provide the opportunities and tools needed for us, as hospital medicine providers, to offer the best palliative care possible to our patients. If successful, we’ll feel the deep personal satisfaction and self-reward of helping a patient and their family transition from hopes of a cure to comfort in the knowledge that their symptoms and needs will be cared for.
Interested in joining the task force or participating in a related work group? Contact Chad Whelan at email@example.com.
The Stroke Resource Room
SHM’s Web site features stroke information on call
Online resource rooms comprise an innovative venue within the SHM Web site to focus on essential topics from the forthcoming core curriculum. Specifically, the Web-based resource rooms organize expert opinions, evidence-based literature, clinical tools and guidelines, and recommendations about essential topics in hospital medicine. Initial areas of development include the DVT and stroke resource rooms, with ongoing efforts in other areas including geriatrics, antimicrobial resistance, congestive heart failure, and glycemic control. These interactive rooms help connect hospitalists to information, content experts, and each other.
The Stroke Imperative
Stroke is the third leading cause of death in the United States and a common admission diagnosis. Cerebrovascular disease is a field of great complexity and rapid advance. There is great pressure on the practicing hospitalist to have both a base knowledge of the approach to the patient with stroke as well as an understanding of current best practice.
Traditional internal medicine residencies may not fully prepare one for hospitalist practice. Many patients seen by hospitalists have diagnoses that were managed by internal medicine subspecialties in the past. Most hospitalists feel comfortable managing straightforward gastrointestinal bleeds, myocardial infarctions, and renal failure without consultation. Neurologic cases are somewhat different.
Most medicine residents have rotated on a neurology service, but that limited experience is frequently insufficient in preparing physicians for their future experience as hospitalists. While neurology residencies include one year of internal medicine, the two diverge dramatically afterward. Practitioners of both internal medicine and neurology frequently feel that they speak a different language from one another.
Particularly in the community setting, hospitalists manage the bulk of neurology patients either with or without neurologic consultation. The reasons for this are varied, including poor inpatient reimbursement for neurologists and a tradition of nonaggressive approaches to stroke care.1
Realizing the need to provide direct access to important information about inpatient stroke management, SHM convened a stroke advisory board, including general hospitalists, a neurologist, and members of the education committee. SHM and Boehringer-Ingelheim provided funding for the resource room through educational funds and an unrestricted grant, respectively.
Stroke Resource Room Content
The Stroke Resource Room is patterned after the template of the DVT Resource Room; the idea being that a standardized format will allow easy navigation and maximal utility. David Likosky, MD, served as content editor, Sandeep Sachdeva, MD, as quality editor, Alpesh Amin, MD as education editor, and Jason Stein, MD, as managing editor.
The rooms are structured to facilitate access to specific types of information. Whether one is looking for the details of a certain study, slide sets to help teach residents, or for input on how to approach a difficult patient, that resource should be readily available. The main sections of the room are summarized below.
The “Awareness” area on the main page of the Stroke Resource Room defines the effects of stroke as well as the hospitalists’ scope of practice.
A separate debate is ongoing within neurology about who should be responsible for the inpatient management of stroke. Interestingly, much of this is about whether general neurologists or vascular/stroke neurologists should primarily manage these patients. One such article referred to the brain as “… the Rolls Royce of the human body” going on to ask, “Would you want your Rolls Royce to be serviced by any ordinary mechanic, who takes care of all kinds of automobiles?”2 Many hospitalists find this argument less than compelling given how difficult it can be in many communities to get a neurologist much less a “vascular neurologist” to see an inpatient.
The “Evidence” section consists of two main parts with the goal of providing a one-stop shop for stroke care literature. The first is a set of links to articles reviewed by the ACP journal club. The second is a concise list of landmark trials, such as the Heparin Acute Embolic Stroke HAEST) trial, which compared low molecular weight heparin versus aspirin in patients with acute stroke and atrial fibrillation.3 These articles help answer questions that come up commonly in clinical practice.
The Experience link capitalizes on the Internet’s ability to disseminate information. There are a limited number of protocols and order sets for ischemic and hemorrhagic stroke available. One can download these and, perhaps more importantly, submit one’s own—including comments on what about that particular tool has been valuable.
Finally, the “Ask the Expert” section features an interactive venue for interacting with a panel of neurologists and neurocritical care physicians. This section answers the more common and more difficult clinical questions in a shared forum. Supportive evidence is cited, with the knowledge that much of stroke care remains in the realm of standard of practice.
The “Improve” section reflects the other roles of hospitalists, such as hospital leader. The three current links include a PowerPoint primer on quality improvement. In addition, there are links to the “Get with the Guidelines” program from the American Stroke Association. This is a continuous quality improvement program focusing on care team protocols and outcome measurement. The final linked site is to the criteria for the disease specific accreditation program from JCAHO. This national effort may drive where patients receive their care for certain conditions.
The “Educate” section caters to multiple audiences. The academic hospitalist may find the “Teaching Pearls” section helpful, as well as the slide sets from the International Stroke Conference and StrokeSTOP, which is aimed at medical students. The patient education links contain a wealth of quality information. The “Professional Development” subsection contains sources for audio lectures with slide sets as well as case presentations and NIH stroke scale training—all with free CME hours. A chapter on stroke from the SHM’s forthcoming core competencies is included as well.
One of the advantages of an Internet-based resource is the ability to be easily modified. A progressively more robust database will be developed over time as questions are answered in the “Ask the Expert” section and as participants share their stroke care protocols.
The Stroke Resource Room is an excellent forum to improve clinical care and form the basis for future SHM workshops, lectures, and to review articles. By building our collective knowledge, we will be limited only by the energy we put into the adding to and using available information and our desire to apply that energy to patient care.
- Likosky DJ, Amin AN. Who will care for our hospitalized patients? Stroke. 2005;36(6): 1113-1114.
- Caplan L. Stroke is best managed by neurologists. Stroke. 2003;34(11):2763.
- Berge E, Abdelnoor M, Nakstad PH, et al. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomized study. HAEST Study Group. Lancet. 2000;355(9211):1205-1210.
Secure the Future
Encourage trainees to consider lifelong careers in hospital medicine
By Vineet Arora, MD, MA, and Margaret C. Fang, MD, MPH, co-chairs of SHM’s Young Physicians Section
Interest in hospital medicine is booming, and it is estimated that the number of hospitalists in the United States is estimated will exceed the number of cardiologists in the near future. Yet, many graduating residents view hospital medicine as a temporary job where they can take time off and work before going on to a subspecialty fellowship. Others perceive hospitalists as “super-residents” susceptible to burnout, and therefore do not consider hospital medicine a sustainable career option. These perceptions may contribute to a high turnover of hospitalists and compromise the accumulation of enough inpatient experience to accomplish many of the benefits associated with the use of hospitalists, including shorter lengths of stay and comparable—if not better—quality of care.
To ensure recruitment and retention of the best and brightest trainees, it’s important to consider ways to educate and encourage them to consider a career in hospital medicine as a rewarding lifelong career. Below, we discuss strategies to encourage trainees to pursue a lifelong career in hospital medicine.
Showcase Your Clinical Work
First, consider your everyday practice an excellent way to showcase the often-exciting world of inpatient medicine. Preclinical students often cherish any opportunity to interact with patients. Inviting first- or second-year medical students to accompany you on rounds is an excellent opportunity to teach clinical medicine and physical exam skills, and a good way to influence their career choice early in their medical career.
If you’re in an academic medical center, accessing preclinical students is as easy as approaching students in an internal medicine interest group or volunteering as a preceptor for a physical diagnosis course for preclinical students. In fact, hospitalists are often acknowledged as some of the best teachers and are highly accessible because of their inpatient duties.
Community-based hospitalists also can provide valuable career advice and opportunities, particularly in exposing students to real-life career experiences often not covered through traditional medical school training. One way for a community-based hospitalist to become involved is to host preclinical students over the summer by contacting a local medical school dean’s office and volunteering as a summer preceptor for interested preclinical students. Your alma mater may be particularly responsive. Or, contact interest groups in internal medicine, family medicine, or pediatrics through the state or local leaders of the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics.
Explain Your Nonclinical Work
It’s important to explain your nonclinical roles to residency trainees. Hospitalists increasingly take on numerous administrative, educational, and leadership roles and responsibilities. Whether you are leading a quality improvement effort, interfacing with hospital operations, or running a medical student clerkship, it is crucial that physicians-in-training understand the diverse opportunities within hospital medicine to achieve a healthy work-life balance and avoid clinical burnout.
If you are involved with quality improvement projects at your institution, enlist the help of an interested resident or student. Because student rotations are frequent, their prior experience may be scant and their time limited. So make sure the projects have definite goals and are easily accomplished. Ensure that the projects provide reasonable educational value and experience within a finite time. Lay out explicit goals at the beginning of the project, ask for frequent updates, and then recap the experience and any concrete accomplishments to provide structure and expectations for the process.
For example, the University of California at San Francisco Hospitalist Group is spearheading an educational initiative in which residents learn about both the theory and practice of quality improvement through choosing a project and working with a mentor to design, implement, and measure the results of a quality improvement initiative.
Share Your Passion
In addition to showcasing your clinical and nonclinical activities, share your passion about hospital medicine. Reflect on the reasons you entered hospital medicine, as well as your thoughts on the pros and cons of the field. Perhaps you were drawn to hospital medicine because of a desire to take care of acutely ill patients, or to work on improving the quality of a medical system, or because of a more controllable work schedule with competitive compensation.
In some cases, it may have been a particular interest in medical ethics, palliative care, geriatrics, or perioperative care. Sharing your enthusiasm is the best way to cultivate reciprocal interest. Medical students and residents closely observe your attitudes toward your career, your job satisfaction, and your work-life balance. In addition to mentoring those already entering a medical career, there are endless opportunities to outreach to younger students, including those in high school and college. Many local schools and community organizations offer mentorship programs to area students. Engaging in an informal discussion about your career at a social or community event with younger students can be incredibly rewarding. Younger students often lack realistic career experiences and access to career-specific role models on which to base informed decisions. Although they may express an interest in science or medicine, they may not know how long the training process is or the importance of good grades.
Take a moment to inquire about career interests and explain what a hospitalist is; this can be invaluable in promoting understanding and cultivating interest into the field. More structured interactions with hospitalists can also prepare students for successful entry into the medical field. The University of Chicago Hospitalists, for example, host high-achieving Chicago public school juniors in a summer clinical and research enrichment program in hospital-based medicine called TEACH Research.
Offer Advice and Assistance
Finding your first job can be a nerve-racking situation. Sharing your advice on the process with trainees is always appreciated. For instance, they are interested in hearing how you decided to become a hospitalist and what you did to secure your position.
Offer to meet with them and review their career interests, goals, and curriculum vitae. If you hear of job openings and opportunities, inform the community of trainees by contacting program directors or chief residents at residency programs. Many residency program directors showcase available opportunities in their house-staff office or direct such opportunities to interested residents. Some residency programs invite community-based physicians to give residents insight on securing their first job. This process is particularly foreign to medical trainees who have never had to negotiate such things as benefit packages, compensation, or call schedule. Your candid thoughts on what to expect and how to approach the process are invaluable.
Again, approaching the residency program where you trained is a good starting point. Alternatively, you can locate a nearby residency through the Fellowship and Residency Electronic Interactive Database database offered by the American Medical Association (www.ama-assn.org/vapp/freida/srch/).
Finally, if you know any trainees interested in hospital medicine,encourage them to attend the SHM’s local or national meetings. The annual meeting is an excellent place for medical trainees to hear the latest research and innovations, learn about advanced training and job opportunities, network, and connect with mentors through the Mentorship Breakfast. For the last two years, the Young Physicians Section has organized a Forum for Early Career Hospitalists where we addressed different career paths in hospital medicine and conducted research during training. Continued growth in our field depends on promoting hospital medicine as a vital, sustainable career.
Busy Summer for HQPS
The Health Quality and Patient Safety Committee (HQPS) has developed an array of initiatives to support SHM members in the development, implementation, and evaluation of quality and system improvements at their institutions. Educational programming, tools, and resources are being developed for four specific content areas including prevention of VTE, improving the discharge process, glycemic control, and improving outcomes for hospitalized heart failure patients.
HQPS members and Course Directors Greg Maynard, MD, and Tosha Wetterneck, MD, are developing a quality precourse for the 2006 SHM Annual Meeting. The educational goal for the precourse will be to enable hospitalists to become leaders in quality and safety through the effective implementation of evidence-based, high reliability interventions. Precourse participants will actively participate in small groups to apply techniques for designing, implementing, and evaluating quality improvement projects to address a specific improvement need in one of four areas: heart failure care, glycemic control, and preventing VTE in the hospital or the discharge process. Registration for this precourse will begin in November and space will be limited. Plan to register early.
In June, HQPS convened a multidisciplinary, multiagency Heart Failure Advisory Board to guide the development of a clinical guidelines implementation toolkit (CGIT), resource room, and CME modules related to implementing best practices for care of patients with heart-failure. The advisory board has representatives from several organizations and allied health professions, including the American College of Cardiology, American Medical Directors Association, American Hospital Association, Case Managers Society of America, American Association of Heart Failure Nurses, American Society of Health-System Pharmacists, American Association of Critical Care Nurses, National Association of Social Workers and the Heart Failure Society of America. Currently, the advisory board is completing a needs assessment and will begin development on the CGIT, resource room and CME modules next month.
In July, in collaboration with the Education Committee and SHM staff, HQPS launched the SHM VTE Resource Room (www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=6312). The resource room provides users with a workbook, or step-wise process to assess the need for VTE prevention, advocate for local improvements, and implement and evaluate a VTE prevention program. The resource room also provides a useful review of the literature, an “Ask the Expert” forum, slide sets, and bedside teaching tools.
In August, the SHM Executive Committee approved the SHM Discharge Planning Checklist developed by HQPS under the direction of Dennis Manning, MD. This discharge planning checklist and a white paper on guidance for its implementation will be available to members in the near future.
Interested in learning more about these initiatives or becoming involved in an HQPS workgroup? Contact Lakshmi Halasyamani, MD, HQPS chair, at HalasyaL@trinity-health.org.
Hartford Grants Awarded
SHM presents Hartford Foundation grant funds to hospitalists for QI demo project
By Kathleen K. Frampton, RN, MPH
Shm remains committed to expanding its efforts to improve inpatient care for older patients. The John A. Hartford Foundation has generously awarded approximately $370,000 to SHM in support of its focus on the geriatric population. This funding will assist SHM in its endeavors related to educational programs and products, hospitalist leadership training, and quality improvement projects. In light of this, SHM allocated a portion of these Hartford grant funds to study a critical aspect of elderly patient care, safety-care transitions.
A competitive request for the proposal (RFP) process was conducted to solicit interest from healthcare institutional providers and SHM members willing to serve as the principle investigator in their work setting. The RFP delineated the requirements for a hospital to serve as a designated study site to implement a discharge planning intervention from hospital-based care to community-based care for elderly patients and to evaluate the facilitating factors, barriers to implementation and outcomes associated with the new approach.
All research proposals submitted by hospitals were evaluated and scored against established criteria. Qualifying hospital finalists were reviewed by a panel consisting of members of three standing SHM Committees: Education, Hospital Quality and Patient Safety, and Research and Executive. In July 2005, this panel selected three hospitals to receive funding for this initiative: Johns Hopkins-Bayview, Baltimore, Md.; Northeast Medical Center, Concord, N.C.; and Geisinger Health System, Danville, Penn.
Johns Hopkins-Bayview (coordinating site): A 355-bed community-based facility located in southeast Baltimore with academic affiliations and approximately 25% of patients over age 65. The hospitalist service consists of nine physicians, five physician assistants, and three nurse practitioners.
Northeast Medical Center: A 457-bed, private, nonprofit community-based facility located in the Charlotte Region with a residency training program and 36% of patients over age 65. The hospitalist service consists of 16 physicians and 24/7 intensivist coverage.
Geisinger Health System: A 366-bed facility and Level 1 Trauma Center, private, nonprofit community based system located in north central Pennsylvania with a residency training program and 70% of patients over age 65. The hospitalist service is staffed by 15 physicians (10 full-time employees).
The QI Demonstration Project will run for 18 months and, according to Tina Budnitz, MPH, SHM senior advisor for planning and development, the study “represents new territory for both SHM and other professional societies … . We have moved beyond developing a best practice to use in the clinical setting to how you can actually change the system so that best practices can be successfully implemented … . It is the intention of SHM to focus on safe practice interventions that can be generalized to other settings.”
Budnitz also explained that near completion of the project SHM plans to convene the advisory board, grantee project teams, representatives of the Hartford Foundation, and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) to review the data from the demonstration project and design a larger scale quality improvement program.
“Our grantees will work with the SHM Advisory Board to develop a comprehensive toolkit, which will document the lessons learned during the implementation process and any other resources that facilitate adaptation and/or adoption of these safe practice interventions,” explains Budnitz.
Care Transitions in the Treatment of the Elderly
According to the Institute of Medicine (IOM), the healthcare system is poorly organized to meet its current challenges. The delivery of care is often overly complex and uncoordinated, requiring steps and patient hand-offs that slow care and decrease rather than improve patient safety.
An IOM seminal report published in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasizes that cumbersome processes waste resources, leave unaccountable voids in coverage, lead to loss of information, and fail to build on the strengths of all professionals involved to ensure that care is appropriate, timely, and safe. Right before and after discharge, there often is no one clearly in charge of the transition whom the patient may contact for guidance. Patients are often instructed to contact their primary care provider for follow-up issues or questions, whether or not the primary care provider had been involved in the hospitalization.
A recent study supported by the Agency for Healthcare Research and Quality (AHRQ) showed that high-risk patient targeting, better communications, and better coordination of care and follow-up could potentially prevent some readmissions when transitioning patients from hospital to home.
In 2002, the American Geriatric Society (AGS) issued a Position Statement, Improving the Quality of Transitional Care for Persons with Complex Care Needs, which stressed that both the “sending” and “receiving” health professionals bear responsibility and accountability in this phase. Successful transitions require that there be both a uniform plan of care and procedure for communicating the following:
- An accessible medical record that contains a current problem list;
- A medication regimen;
- A list of allergies;
- Advance directives;
- Baseline physical and cognitive function; and
- Contact information for all professional and informal care providers.
Also, input must be solicited from informal care providers who are involved in the execution of the plan of care. The AGS recommends the use of a “coordinating” health professional who oversees both the sending and receiving aspects of the transition. This professional should be skilled in the identification of health status, assessment and management of multiple chronic conditions, managing medications, and collaboration with members of the interdisciplinary team and caregivers.
The QI Demonstration Project
According to SHM Immediate Past-President Jeanne Huddleston, MD, SHM has structured this demonstration project so that the three study sites in the Hartford Grant Group will implement identical clinical tools while they employ unique processes and procedures at each of the individual sites.
“The what needs to be in common across sites, but the how and who in the implementation will be individually tailored to each specific hospital environment,” she explains.
This is a real strength of the study because standardized interventions can be studied in varied and representative test environments. Dr. Huddleston also stresses that, “SHM envisions its role in quality management to be in the actual implementation realm—rather than in the development of new clinical guidelines. SHM seeks to know whether hospitalists [use] the same tools at different sites and understand their impact at each site.”
The patient care domains selected as a focus for the safe practice implementation tools for the care transition process are:
- Medication reconciliation; and
- Functional status.
Communication tools will be developed for primary care physicians, patients, and their support systems so that important clinical information is transmitted during the discharge process. The implementation tools designed for medication reconciliation will be employed by physicians, care managers, or pharmacists in the hospital. Transmitting the medication regimen is widely recognized as an error-prone element of care. These specific implementation tools will include a method to review and verify any dose/frequency changes of medications that the patient was taking upon admission, as well as those that were added or discontinued during the inpatient episode. Because patient functional status is a critical issue in discharge planning, detailed tools will also be created to standardize content for risk assessment and evaluation of the types of assistance needed for patients to resume activities of daily living.
The demonstration project will also utilize specific metrics to measure patient outcomes as well as the effect that these safe practices have on the discharge and care transition processes. The three study sites will measure referring physician satisfaction with the adequacy of post-hospitalization follow-up information, the accuracy of medication reconciliation, readmission rates, and patient understanding of their treatment plan and medication regimen.
QI Requires Expert Change Management
Hospitalists recognize that the challenge of patient safety is linked to the challenge of organizational change. Patient safety initiatives can succeed only to the extent to which healthcare organizations recognize the need for and develop the means to implement the organizational changes. According to the AHRQ, systemwide improvements in patient safety are possible only if there are coordinated changes in multiple components—clinical procedures, attitudes and behaviors of care providers, incentive systems, coordination structures and processes, patterns of interactions among care providers, and organizational culture.
Senior leadership must play an active role in establishing patient safety as a priority, and staff involved directly in providing care must actively participate in implementing change. The likelihood of successful implementation of even simple change requires multiple tactics or many bullets directed at the same target. Additionally, it is critical to redesign the roles of healthcare workers at the point of care to accommodate the necessary changes and to retrain them to fulfill these roles.
Hospitalists Prepare to Lead
Identifying the facilitating factors and barriers to improvement is essential to effect change because it helps ensure success. It’s also crucial to match the patient safety goals with the change strategies and tactics. Otherwise, mismatches can lead to unintended consequences that will hinder continuous improvements such as employee skepticism, frustration of safety champions, and mislearning or unnecessary ”workarounds“ by staff.
SHM sees this QI Demonstration Project as critical to assisting institutions in the design, implementation, and evaluation of QI programs and systemwide interventions with effectiveness and value. These findings should equip hospitalists with vital tools necessary to provide essential leadership in meeting their institution’s quality and patient safety goals. TH
Writer Kathleen Frampton is based in Columbia, Md