Li-Kheng Ngov, MD

Studies continue to demonstrate persistent gaps in equity for women and underrepresented minorities (URMs)¹ throughout nearly all aspects of academic medicine, including rank,^2-4 tenure,⁵ authorship,^6,7 funding opportunities,^8,9 awards,¹⁰ speakership,¹¹ leadership,^12,13 and salaries.^2,14,15 Hospital medicine, despite being a newer field,¹⁶ has also seen these disparities^17,18; however, there are numerous efforts in place to actively change our specialty’s course.^19-22 Hospital medicine is a field known for being a change agent in healthcare delivery,²² and its novel approaches are well poised to fundamentally shatter the glass ceilings imposed on traditionally underrepresented groups in medicine. The importance of diversity, equity, and inclusion (DEI) initiatives in healthcare has never been clearer,^23,24 particularly as they relate to cultural competence^25-28 and cultural humility,^29,30 implicit and explicit bias,²⁷ expanding care for underserved patient populations, supporting our workforce, and broadening research agendas.²⁸

In this article, we report DEI efforts within our division, focusing on the development of our strategic plan and specific outcomes related to compensation, recruitment, and policies.

Our Division’s Framework to DEI—“It Takes a Village”

Our Division of Hospital Medicine (DHM), previously within the Division of General Internal Medicine, was founded in October 2017. The DHM at the University of Colorado Hospital (UCH) is composed of 100 faculty members (70 physicians and 30 advanced-practice providers; 58% women and 42% men). In 2018, we implemented a stepwise approach to critically assess DEI within our group and to build a strategic plan to address the issues. Key areas of focus included institutional structures, our people, our environments, and our core missions (Figure 1 and Appendix Figure 1). DHM members helped drive our work and partnered with departmental, hospital, and school of medicine committees; national organizations; and collaborators to enhance implementation and dissemination efforts. In addition to stakeholder engagement, we utilized strategic planning and rapid Plan-Do-Study-Act (PDSA) cycles to advance DEI work in our DHM.

Needs Assessment

As a new division, we sought stakeholder feedback from division members. All faculty within the division were invited to attend a meeting in which issues related to DEI were discussed. A literature review that spanned both medical and nonmedical fields was also completed. Search terms included salary equity, gender equity, diverse teams, diversity recruitment and retention, diversifying leadership, and diverse speakers. Salaries, internally funded time, and other processes, such as recruitment, promotion, and hiring for leadership positions, were evaluated during the first year we became a division.

Interventions

TThrough this work, and with stakeholder engagement, we developed a divisional strategic plan to address DEI globally. Our strategic plan included developing a DEI director role to assist with overseeing DEI efforts. We have highlighted the various methods utilized for each component (Figure 1). This work occurred from October 2017 to December 2018.

Our institutional structures

Using best practices from both medical and nonmedical fields, we developed evidence-based approaches to compensation,³¹ recruitment,³² and policies that support and foster a culture of DEI.³² These strategies were used to support the following initiatives:

Compensation: transparent and consistent approaches based upon benchmarking with a framework of equal pay for equal work and similar advanced training/academic rank. In conjunction with efforts within the School of Medicine (SOM), Department of Medicine (DOM), and the UCH, our division sought to study salaries across DHM faculty members. We had an open call for faculty to participate in a newly developed DHM Compensation Committee, with the intent of rigorously examining our compensation practices and goals. Through faculty feedback and committee work, salary equity was defined as equal pay (ie, base salary for one clinical full-time equivalent [FTE]) for equal work based on academic rank and/or years of practice/advanced training. We also compared DHM salaries to regional academic hospital medicine groups and concluded that DHM salaries were lower than local and national benchmarks. This information was used to create a two-phase approach to increasing salaries for all individuals below the American Association of Medical Colleges (AAMC) benchmarks³³ for academic hospitalists. We also developed a stipend system for external roles that came with additional compensation and roles within our own division that came with additional pay (ie, nocturnist). Phase 1 focused on those whose salaries were furthest away from and below benchmark, and phase 2 targeted all remaining individuals below benchmark.

A similar review of FTEs (based on required number of shifts for a full-time hospitalist) tied to our internal DHM leadership positions was completed by the division head and director of DEI. Specifically, the mission for each of our internally funded roles, job descriptions, and responsibilities was reviewed to ensure equity in funding.

Recruitment and advancement: processes to ensure equity and diversity in recruitment, tracking, and reporting, working to eliminate/mitigate bias. In collaboration with members of the AAMC Group on Women in Medicine and Science (GWIMS) and coauthors from various institutions, we developed toolkits and checklists aimed at achieving equity and diversity within candidate pools and on major committees, including, but not limited to, search and promotion committees.³² Additionally, a checklist was developed to help recruit more diverse speakers, including women and URMs, for local, regional, and national conferences.

Policies: evidence-based approaches, tracking and reporting, standardized approaches to eliminate/mitigate bias, embracing nontraditional paths. In partnership with our departmental efforts, members of our team led data collection and reporting for salary benchmarking, leadership roles, and committee membership. This included developing surveys and reporting templates that can be used to identify disparities and inform future efforts. We worked to ensure that we have faculty representing our field at the department and SOM levels. Specifically, we made sure to nominate division members during open calls for departmental and schoolwide committees, including the promotions committee.

Our People

The faculty and staff within our division have been instrumental in moving efforts forward in the following important areas.

Leadership: develop the position of director of DEI as well as leadership structures to support and increase DEI. One of the first steps in our strategic plan was creating a director of DEI leadership role (Appendix Figure 2). The director is responsible for researching, applying, and promoting a broad scope of DEI initiatives and best practices within the DHM, DOM, and SOM (in collaboration with their leaders), including recruitment, retention, and promotion of medical students, residents, and faculty; educational program development; health disparities research; and community-engaged scholarship.

Support: develop family leave policies/develop flexible work policies. Several members of our division worked on departmental committees and served in leadership roles on staff and faculty council. Estimated costs were assessed. Through collective efforts of department leadership and division head support, the department approved parental leave to employees following the birth of an employee’s child or the placement of a child with an employee in connection with adoption or permanent foster care.

Mentorship/sponsorship: enhance faculty advancement programs/develop pipeline and trainings/collaborate with student groups and organizations/invest in all of our people. Faculty across our divisional sites have held important roles in developing pipeline programs for undergraduate students bound for health professions, as well as programs developed specifically for medical students and internal medicine residents. This includes two programs, the CU Hospitalist Scholars Program (CUHSP) and Leadership Education for Aspiring Doctors (LEAD), in which undergraduate students have the opportunity to round with hospital medicine teams, work on quality-improvement projects, and receive extensive mentorship and advising from a diverse faculty team. Additionally, our faculty advancement team within the DHM has grown and been restructured to include more defined goals and to ensure each faculty member has at least one mentor in their area of interest.

Supportive: lactation space and support/diverse space options/inclusive and diverse environments. We worked closely with hospital leadership to advocate for adequately equipped lactation spaces, including equipment such as pumps, refrigerators, and computer workstations. Additionally, our team members conducted environmental scans (eg, identified pictures, artwork, or other images that were not representative of a diverse and inclusive environment and raised concerns when the environment was not inclusive).

Measures

Our measures focused on (1) development and implementation of our DEI strategic plan, including new policies, processes, and practices related to key components of the DEI program; and (2) assessment of specific DEI programs, including pre-post salary data disparities based on rank and pre-post disparities for protected time for similar roles.

Analysis

Through rapid PDSA cycles, we evaluated salary equity, equity in leadership allotment, and committee membership. We have developed a tracking board to track progress of the multiple projects in the strategic plan.

Strategic Plan Development and Tracking

From October 2017 to December 2018, we developed a robust strategic plan and stepwise approach to DEI (Figure 1 and Figure 2). The director of DEI position was developed (see Appendix Figure 2 for job description) to help oversee these efforts. Figure 3 highlights the specific efforts and the progress made on implementation (ie, high-level dashboard or “tracking board”). While outcomes are still pending in the areas of recruitment and advancement and environment, we have made measurable improvements in compensation, as outlined in the following section.

Compensation

One year after the salary-equity interventions, all of our physician faculty’s salaries were at the goal benchmark (Table), and differences in salary for those in similar years of rank were nearly eliminated. Similarly, after implementing an internally consistent approach to assigning FTE for new and established positions within the division (ie, those that fall within the purview of the division), all faculty in similar types of roles had similar amounts of protected time.

Recruitment and Advancement

Toolkits³² and committee recommendations have been incorporated into division goals, though some aspects are still in implementation phases, as division-wide implicit bias training was delayed secondary to the COVID-19 pandemic. Key goals include: (1) implicit bias training for all members of major committees; (2) aiming for a goal of at least 40% representation of women and 40% URMs on committees; (3) having a diversity expert serve on each committee in order to identify and discuss any potential bias in the search and candidate-selection processes; and (4) careful tracking of diversity metrics in regard to diversity of candidates at each step of the interview and selection process.

Surveys and reporting templates for equity on committees and leadership positions have been developed and deployed. Data dashboards for our division have been developed as well (for compensation, leadership, and committee membership). A divisional dashboard to report recruitment efforts is in progress.

We have successfully nominated several faculty members to the SOM promotions committee and departmental committees during open calls for these positions. At the division level, we have also adapted internal policies to ensure promotion occurs on time and offers alternative pathways for faculty that may primarily focus on clinical pathways. All faculty who have gone up for promotion thus far have been successfully promoted in their desired pathway.

Environment

We successfully advocated and achieved adequately equipped lactation spaces, including equipment such as pumps, refrigerators, and computer workstations. This achievement was possible because of our hospital partners. Our efforts helped us acquire sufficient space and facilities such that nursing mothers can pump and still be able to answer phones, enter orders, and document visits.

Our team members conducted environmental scans and raised concerns when the environment was not inclusive, such as conference rooms with portraits of leadership that do not show diversity. The all-male pictures were removed from one frequently used departmental conference room, which will eventually house a diverse group of pictures and achievements.

We aim to eliminate bias by offering implicit bias training for our faculty. While this is presently required for those who serve on committees, in leadership positions, or those involved in recruitment and interviewing for the DOM, our goal is to eventually provide this training to all faculty and staff in the division. We have also incorporated DEI topics into our educational conferences for faculty, including sessions on recognizing bias in medicine, how to be an upstander/ally, and the impact of race and racism on medicine.

DISCUSSION

The important findings of this work are: (1) that successes in DEI can be achieved with strategic planning and stakeholder engagement; (2) through simple modification of processes, we can improve equity in compensation and FTE allotted to leadership; (3) though it takes time, diversity recruitment can be improved using sound, sustainable, evidence-based processes; (4) this work is time-intensive and challenging, requiring ongoing efforts to improve, modify, and enhance current efforts and future successes.

We have certainly made some progress with DEI initiatives within our division and have also learned a great deal from this experience. First, change is difficult for all parties involved, including those leading change and those affected by the changes. We purposely made an effort to facilitate discussions with all of the DHM faculty and staff to ensure that everyone felt included in this work and that everyone’s voice was heard. This was exemplified by inviting all faculty members to a feedback session in which we discussed DEI within our division and areas that we wanted to improve on. Early on, we were able to define what diversity, equity, and inclusion meant to us as a division and then use these definitions to develop tangible goals for all the areas of highest importance to the group.

By increasing faculty presence on key committees, such as the promotions committee, we now have faculty members who are well versed in promotions processes. We are fortunate to have a promotions process that supports faculty advancement for faculty with diverse interests that spans from supporting highly clinical faculty, clinician educators, as well as more traditional researchers.³⁴ By having hospitalists serve in these roles, we help to add to the diverse perspectives on these committees, including emphasizing the scholarship that is associated with quality improvement, as well as DEI efforts which can often be viewed as service as opposed to scholarship.

Clear communication and transparency were key to all of our DEI initiatives. We had monthly updates on our DEI efforts during business meetings and also held impromptu meetings (also known as flash mobs³⁵) to answer questions and discuss concerns in real time. As with all DEI work, it is important to know where you are starting (having accurate data and a clear understanding of the data) and be able to communicate that data to the group. For example, using AAMC salary benchmarking³³ as well as other benchmarks allowed us to accurately calculate variance among salaries and identify the appropriate goal salary for each of our faculty members. Likewise, by completing an in-depth inventory on the work being done by all of our faculty in leadership roles, we were able to standardize the compensation/FTE for each of these roles. Tracking these changes over time, via the use of dashboards in our case, allows for real-time measurements and accountability for all of those involved. Our end goal will be to have all of these initiatives feed into one large dashboard.

Collaborating with leadership and stakeholders in the DOM, SOM, and hospital helped to make our DEI initiatives successful. Much too often, we work in silos when it comes to DEI work. However, we tend to have similar goals and can achieve much more if we work together. Collaboration with multiple stakeholders allowed for wider dissemination and resulted in a larger impact to the campus and community at large. This has been exemplified by the committee composition guidance that has been utilized by the DOM, as well as implementation of campus-wide policies, specifically the parental leave policy, which our faculty members played an important role in creating. Likewise, it is important to look outside of our institutions and work with other hospital medicine groups around the country who are interested in promoting DEI.

We still have much work ahead of us. We are continuing to measure outcomes status postimplementation of the toolkit and checklists being used for diversity recruitment and committee composition. Additionally, we are actively working on several initiatives, including:

• Instituting implicit bias training for all of our faculty
• Partnering with national leaders and our hospital systems to develop zero-tolerance policies regarding abusive behaviors (verbal, physical, and other), racism, and sexism in the hospital and other work settings
• Development of specific recruitment strategies as a means of diversifying our healthcare workforce (of note, based on a 2020 survey of our faculty, in which there was a 70% response rate, 8.5% of our faculty identified as URMs)
• Completion of a diversity dashboard to track our progress in all of these efforts over time
• Development of a more robust pipeline to promotion and leadership for our URM faculty

This study has several strengths. Many of the plans and strategies described here can be used to guide others interested in implementing this work. Figure 2 provides a stepwise
approach to addressing DEI in hospital medicine groups and divisions. We conducted this work at a large academic medical center, and while it may not be generalizable, it does offer some ideas for others to consider in their own work to advance DEI at their institutions. There are also several limitations to this work. Eliminating salary inequities with our approach did take resources. We took advantage of already lower salaries and the need to increase salaries closer to benchmark and paired this effort with our DEI efforts to achieve salary equity. This required partnerships with the department and hospital. Efforts to advance DEI also take a lot of time and effort, and thus commitment from the division, department, and institution as a whole is key. While we have outcomes for our efforts related to salary equity, recruitment efforts should be realized over time, as currently it is too early to tell. We have highlighted the efforts that have been put in place at this time.

Using a systematic evidence-based approach with key stakeholder involvement, a division-wide DEI strategy was developed and implemented. While this work is still ongoing, short-term wins are possible, in particular around salary equity and development of policies and structures to promote DEI.

Studies continue to demonstrate persistent gaps in equity for women and underrepresented minorities (URMs)¹ throughout nearly all aspects of academic medicine, including rank,^2-4 tenure,⁵ authorship,^6,7 funding opportunities,^8,9 awards,¹⁰ speakership,¹¹ leadership,^12,13 and salaries.^2,14,15 Hospital medicine, despite being a newer field,¹⁶ has also seen these disparities^17,18; however, there are numerous efforts in place to actively change our specialty’s course.^19-22 Hospital medicine is a field known for being a change agent in healthcare delivery,²² and its novel approaches are well poised to fundamentally shatter the glass ceilings imposed on traditionally underrepresented groups in medicine. The importance of diversity, equity, and inclusion (DEI) initiatives in healthcare has never been clearer,^23,24 particularly as they relate to cultural competence^25-28 and cultural humility,^29,30 implicit and explicit bias,²⁷ expanding care for underserved patient populations, supporting our workforce, and broadening research agendas.²⁸

In this article, we report DEI efforts within our division, focusing on the development of our strategic plan and specific outcomes related to compensation, recruitment, and policies.

Our Division’s Framework to DEI—“It Takes a Village”

Our Division of Hospital Medicine (DHM), previously within the Division of General Internal Medicine, was founded in October 2017. The DHM at the University of Colorado Hospital (UCH) is composed of 100 faculty members (70 physicians and 30 advanced-practice providers; 58% women and 42% men). In 2018, we implemented a stepwise approach to critically assess DEI within our group and to build a strategic plan to address the issues. Key areas of focus included institutional structures, our people, our environments, and our core missions (Figure 1 and Appendix Figure 1). DHM members helped drive our work and partnered with departmental, hospital, and school of medicine committees; national organizations; and collaborators to enhance implementation and dissemination efforts. In addition to stakeholder engagement, we utilized strategic planning and rapid Plan-Do-Study-Act (PDSA) cycles to advance DEI work in our DHM.

Needs Assessment

As a new division, we sought stakeholder feedback from division members. All faculty within the division were invited to attend a meeting in which issues related to DEI were discussed. A literature review that spanned both medical and nonmedical fields was also completed. Search terms included salary equity, gender equity, diverse teams, diversity recruitment and retention, diversifying leadership, and diverse speakers. Salaries, internally funded time, and other processes, such as recruitment, promotion, and hiring for leadership positions, were evaluated during the first year we became a division.

Interventions

TThrough this work, and with stakeholder engagement, we developed a divisional strategic plan to address DEI globally. Our strategic plan included developing a DEI director role to assist with overseeing DEI efforts. We have highlighted the various methods utilized for each component (Figure 1). This work occurred from October 2017 to December 2018.

Our institutional structures

Using best practices from both medical and nonmedical fields, we developed evidence-based approaches to compensation,³¹ recruitment,³² and policies that support and foster a culture of DEI.³² These strategies were used to support the following initiatives:

Compensation: transparent and consistent approaches based upon benchmarking with a framework of equal pay for equal work and similar advanced training/academic rank. In conjunction with efforts within the School of Medicine (SOM), Department of Medicine (DOM), and the UCH, our division sought to study salaries across DHM faculty members. We had an open call for faculty to participate in a newly developed DHM Compensation Committee, with the intent of rigorously examining our compensation practices and goals. Through faculty feedback and committee work, salary equity was defined as equal pay (ie, base salary for one clinical full-time equivalent [FTE]) for equal work based on academic rank and/or years of practice/advanced training. We also compared DHM salaries to regional academic hospital medicine groups and concluded that DHM salaries were lower than local and national benchmarks. This information was used to create a two-phase approach to increasing salaries for all individuals below the American Association of Medical Colleges (AAMC) benchmarks³³ for academic hospitalists. We also developed a stipend system for external roles that came with additional compensation and roles within our own division that came with additional pay (ie, nocturnist). Phase 1 focused on those whose salaries were furthest away from and below benchmark, and phase 2 targeted all remaining individuals below benchmark.

A similar review of FTEs (based on required number of shifts for a full-time hospitalist) tied to our internal DHM leadership positions was completed by the division head and director of DEI. Specifically, the mission for each of our internally funded roles, job descriptions, and responsibilities was reviewed to ensure equity in funding.

Recruitment and advancement: processes to ensure equity and diversity in recruitment, tracking, and reporting, working to eliminate/mitigate bias. In collaboration with members of the AAMC Group on Women in Medicine and Science (GWIMS) and coauthors from various institutions, we developed toolkits and checklists aimed at achieving equity and diversity within candidate pools and on major committees, including, but not limited to, search and promotion committees.³² Additionally, a checklist was developed to help recruit more diverse speakers, including women and URMs, for local, regional, and national conferences.

Policies: evidence-based approaches, tracking and reporting, standardized approaches to eliminate/mitigate bias, embracing nontraditional paths. In partnership with our departmental efforts, members of our team led data collection and reporting for salary benchmarking, leadership roles, and committee membership. This included developing surveys and reporting templates that can be used to identify disparities and inform future efforts. We worked to ensure that we have faculty representing our field at the department and SOM levels. Specifically, we made sure to nominate division members during open calls for departmental and schoolwide committees, including the promotions committee.

Our People

The faculty and staff within our division have been instrumental in moving efforts forward in the following important areas.

Leadership: develop the position of director of DEI as well as leadership structures to support and increase DEI. One of the first steps in our strategic plan was creating a director of DEI leadership role (Appendix Figure 2). The director is responsible for researching, applying, and promoting a broad scope of DEI initiatives and best practices within the DHM, DOM, and SOM (in collaboration with their leaders), including recruitment, retention, and promotion of medical students, residents, and faculty; educational program development; health disparities research; and community-engaged scholarship.

Support: develop family leave policies/develop flexible work policies. Several members of our division worked on departmental committees and served in leadership roles on staff and faculty council. Estimated costs were assessed. Through collective efforts of department leadership and division head support, the department approved parental leave to employees following the birth of an employee’s child or the placement of a child with an employee in connection with adoption or permanent foster care.

Mentorship/sponsorship: enhance faculty advancement programs/develop pipeline and trainings/collaborate with student groups and organizations/invest in all of our people. Faculty across our divisional sites have held important roles in developing pipeline programs for undergraduate students bound for health professions, as well as programs developed specifically for medical students and internal medicine residents. This includes two programs, the CU Hospitalist Scholars Program (CUHSP) and Leadership Education for Aspiring Doctors (LEAD), in which undergraduate students have the opportunity to round with hospital medicine teams, work on quality-improvement projects, and receive extensive mentorship and advising from a diverse faculty team. Additionally, our faculty advancement team within the DHM has grown and been restructured to include more defined goals and to ensure each faculty member has at least one mentor in their area of interest.

Supportive: lactation space and support/diverse space options/inclusive and diverse environments. We worked closely with hospital leadership to advocate for adequately equipped lactation spaces, including equipment such as pumps, refrigerators, and computer workstations. Additionally, our team members conducted environmental scans (eg, identified pictures, artwork, or other images that were not representative of a diverse and inclusive environment and raised concerns when the environment was not inclusive).

Measures

Our measures focused on (1) development and implementation of our DEI strategic plan, including new policies, processes, and practices related to key components of the DEI program; and (2) assessment of specific DEI programs, including pre-post salary data disparities based on rank and pre-post disparities for protected time for similar roles.

Analysis

Through rapid PDSA cycles, we evaluated salary equity, equity in leadership allotment, and committee membership. We have developed a tracking board to track progress of the multiple projects in the strategic plan.

Strategic Plan Development and Tracking

From October 2017 to December 2018, we developed a robust strategic plan and stepwise approach to DEI (Figure 1 and Figure 2). The director of DEI position was developed (see Appendix Figure 2 for job description) to help oversee these efforts. Figure 3 highlights the specific efforts and the progress made on implementation (ie, high-level dashboard or “tracking board”). While outcomes are still pending in the areas of recruitment and advancement and environment, we have made measurable improvements in compensation, as outlined in the following section.

Compensation

One year after the salary-equity interventions, all of our physician faculty’s salaries were at the goal benchmark (Table), and differences in salary for those in similar years of rank were nearly eliminated. Similarly, after implementing an internally consistent approach to assigning FTE for new and established positions within the division (ie, those that fall within the purview of the division), all faculty in similar types of roles had similar amounts of protected time.

Recruitment and Advancement

Toolkits³² and committee recommendations have been incorporated into division goals, though some aspects are still in implementation phases, as division-wide implicit bias training was delayed secondary to the COVID-19 pandemic. Key goals include: (1) implicit bias training for all members of major committees; (2) aiming for a goal of at least 40% representation of women and 40% URMs on committees; (3) having a diversity expert serve on each committee in order to identify and discuss any potential bias in the search and candidate-selection processes; and (4) careful tracking of diversity metrics in regard to diversity of candidates at each step of the interview and selection process.

Surveys and reporting templates for equity on committees and leadership positions have been developed and deployed. Data dashboards for our division have been developed as well (for compensation, leadership, and committee membership). A divisional dashboard to report recruitment efforts is in progress.

We have successfully nominated several faculty members to the SOM promotions committee and departmental committees during open calls for these positions. At the division level, we have also adapted internal policies to ensure promotion occurs on time and offers alternative pathways for faculty that may primarily focus on clinical pathways. All faculty who have gone up for promotion thus far have been successfully promoted in their desired pathway.

Environment

We successfully advocated and achieved adequately equipped lactation spaces, including equipment such as pumps, refrigerators, and computer workstations. This achievement was possible because of our hospital partners. Our efforts helped us acquire sufficient space and facilities such that nursing mothers can pump and still be able to answer phones, enter orders, and document visits.

Our team members conducted environmental scans and raised concerns when the environment was not inclusive, such as conference rooms with portraits of leadership that do not show diversity. The all-male pictures were removed from one frequently used departmental conference room, which will eventually house a diverse group of pictures and achievements.

We aim to eliminate bias by offering implicit bias training for our faculty. While this is presently required for those who serve on committees, in leadership positions, or those involved in recruitment and interviewing for the DOM, our goal is to eventually provide this training to all faculty and staff in the division. We have also incorporated DEI topics into our educational conferences for faculty, including sessions on recognizing bias in medicine, how to be an upstander/ally, and the impact of race and racism on medicine.

DISCUSSION

The important findings of this work are: (1) that successes in DEI can be achieved with strategic planning and stakeholder engagement; (2) through simple modification of processes, we can improve equity in compensation and FTE allotted to leadership; (3) though it takes time, diversity recruitment can be improved using sound, sustainable, evidence-based processes; (4) this work is time-intensive and challenging, requiring ongoing efforts to improve, modify, and enhance current efforts and future successes.

We have certainly made some progress with DEI initiatives within our division and have also learned a great deal from this experience. First, change is difficult for all parties involved, including those leading change and those affected by the changes. We purposely made an effort to facilitate discussions with all of the DHM faculty and staff to ensure that everyone felt included in this work and that everyone’s voice was heard. This was exemplified by inviting all faculty members to a feedback session in which we discussed DEI within our division and areas that we wanted to improve on. Early on, we were able to define what diversity, equity, and inclusion meant to us as a division and then use these definitions to develop tangible goals for all the areas of highest importance to the group.

By increasing faculty presence on key committees, such as the promotions committee, we now have faculty members who are well versed in promotions processes. We are fortunate to have a promotions process that supports faculty advancement for faculty with diverse interests that spans from supporting highly clinical faculty, clinician educators, as well as more traditional researchers.³⁴ By having hospitalists serve in these roles, we help to add to the diverse perspectives on these committees, including emphasizing the scholarship that is associated with quality improvement, as well as DEI efforts which can often be viewed as service as opposed to scholarship.

Clear communication and transparency were key to all of our DEI initiatives. We had monthly updates on our DEI efforts during business meetings and also held impromptu meetings (also known as flash mobs³⁵) to answer questions and discuss concerns in real time. As with all DEI work, it is important to know where you are starting (having accurate data and a clear understanding of the data) and be able to communicate that data to the group. For example, using AAMC salary benchmarking³³ as well as other benchmarks allowed us to accurately calculate variance among salaries and identify the appropriate goal salary for each of our faculty members. Likewise, by completing an in-depth inventory on the work being done by all of our faculty in leadership roles, we were able to standardize the compensation/FTE for each of these roles. Tracking these changes over time, via the use of dashboards in our case, allows for real-time measurements and accountability for all of those involved. Our end goal will be to have all of these initiatives feed into one large dashboard.

Collaborating with leadership and stakeholders in the DOM, SOM, and hospital helped to make our DEI initiatives successful. Much too often, we work in silos when it comes to DEI work. However, we tend to have similar goals and can achieve much more if we work together. Collaboration with multiple stakeholders allowed for wider dissemination and resulted in a larger impact to the campus and community at large. This has been exemplified by the committee composition guidance that has been utilized by the DOM, as well as implementation of campus-wide policies, specifically the parental leave policy, which our faculty members played an important role in creating. Likewise, it is important to look outside of our institutions and work with other hospital medicine groups around the country who are interested in promoting DEI.

We still have much work ahead of us. We are continuing to measure outcomes status postimplementation of the toolkit and checklists being used for diversity recruitment and committee composition. Additionally, we are actively working on several initiatives, including:

• Instituting implicit bias training for all of our faculty
• Partnering with national leaders and our hospital systems to develop zero-tolerance policies regarding abusive behaviors (verbal, physical, and other), racism, and sexism in the hospital and other work settings
• Development of specific recruitment strategies as a means of diversifying our healthcare workforce (of note, based on a 2020 survey of our faculty, in which there was a 70% response rate, 8.5% of our faculty identified as URMs)
• Completion of a diversity dashboard to track our progress in all of these efforts over time
• Development of a more robust pipeline to promotion and leadership for our URM faculty

This study has several strengths. Many of the plans and strategies described here can be used to guide others interested in implementing this work. Figure 2 provides a stepwise
approach to addressing DEI in hospital medicine groups and divisions. We conducted this work at a large academic medical center, and while it may not be generalizable, it does offer some ideas for others to consider in their own work to advance DEI at their institutions. There are also several limitations to this work. Eliminating salary inequities with our approach did take resources. We took advantage of already lower salaries and the need to increase salaries closer to benchmark and paired this effort with our DEI efforts to achieve salary equity. This required partnerships with the department and hospital. Efforts to advance DEI also take a lot of time and effort, and thus commitment from the division, department, and institution as a whole is key. While we have outcomes for our efforts related to salary equity, recruitment efforts should be realized over time, as currently it is too early to tell. We have highlighted the efforts that have been put in place at this time.

Using a systematic evidence-based approach with key stakeholder involvement, a division-wide DEI strategy was developed and implemented. While this work is still ongoing, short-term wins are possible, in particular around salary equity and development of policies and structures to promote DEI.

Studies continue to demonstrate persistent gaps in equity for women and underrepresented minorities (URMs)¹ throughout nearly all aspects of academic medicine, including rank,^2-4 tenure,⁵ authorship,^6,7 funding opportunities,^8,9 awards,¹⁰ speakership,¹¹ leadership,^12,13 and salaries.^2,14,15 Hospital medicine, despite being a newer field,¹⁶ has also seen these disparities^17,18; however, there are numerous efforts in place to actively change our specialty’s course.^19-22 Hospital medicine is a field known for being a change agent in healthcare delivery,²² and its novel approaches are well poised to fundamentally shatter the glass ceilings imposed on traditionally underrepresented groups in medicine. The importance of diversity, equity, and inclusion (DEI) initiatives in healthcare has never been clearer,^23,24 particularly as they relate to cultural competence^25-28 and cultural humility,^29,30 implicit and explicit bias,²⁷ expanding care for underserved patient populations, supporting our workforce, and broadening research agendas.²⁸

In this article, we report DEI efforts within our division, focusing on the development of our strategic plan and specific outcomes related to compensation, recruitment, and policies.

Our Division’s Framework to DEI—“It Takes a Village”

Our Division of Hospital Medicine (DHM), previously within the Division of General Internal Medicine, was founded in October 2017. The DHM at the University of Colorado Hospital (UCH) is composed of 100 faculty members (70 physicians and 30 advanced-practice providers; 58% women and 42% men). In 2018, we implemented a stepwise approach to critically assess DEI within our group and to build a strategic plan to address the issues. Key areas of focus included institutional structures, our people, our environments, and our core missions (Figure 1 and Appendix Figure 1). DHM members helped drive our work and partnered with departmental, hospital, and school of medicine committees; national organizations; and collaborators to enhance implementation and dissemination efforts. In addition to stakeholder engagement, we utilized strategic planning and rapid Plan-Do-Study-Act (PDSA) cycles to advance DEI work in our DHM.

Needs Assessment

As a new division, we sought stakeholder feedback from division members. All faculty within the division were invited to attend a meeting in which issues related to DEI were discussed. A literature review that spanned both medical and nonmedical fields was also completed. Search terms included salary equity, gender equity, diverse teams, diversity recruitment and retention, diversifying leadership, and diverse speakers. Salaries, internally funded time, and other processes, such as recruitment, promotion, and hiring for leadership positions, were evaluated during the first year we became a division.

Interventions

TThrough this work, and with stakeholder engagement, we developed a divisional strategic plan to address DEI globally. Our strategic plan included developing a DEI director role to assist with overseeing DEI efforts. We have highlighted the various methods utilized for each component (Figure 1). This work occurred from October 2017 to December 2018.

Our institutional structures

Using best practices from both medical and nonmedical fields, we developed evidence-based approaches to compensation,³¹ recruitment,³² and policies that support and foster a culture of DEI.³² These strategies were used to support the following initiatives:

Compensation: transparent and consistent approaches based upon benchmarking with a framework of equal pay for equal work and similar advanced training/academic rank. In conjunction with efforts within the School of Medicine (SOM), Department of Medicine (DOM), and the UCH, our division sought to study salaries across DHM faculty members. We had an open call for faculty to participate in a newly developed DHM Compensation Committee, with the intent of rigorously examining our compensation practices and goals. Through faculty feedback and committee work, salary equity was defined as equal pay (ie, base salary for one clinical full-time equivalent [FTE]) for equal work based on academic rank and/or years of practice/advanced training. We also compared DHM salaries to regional academic hospital medicine groups and concluded that DHM salaries were lower than local and national benchmarks. This information was used to create a two-phase approach to increasing salaries for all individuals below the American Association of Medical Colleges (AAMC) benchmarks³³ for academic hospitalists. We also developed a stipend system for external roles that came with additional compensation and roles within our own division that came with additional pay (ie, nocturnist). Phase 1 focused on those whose salaries were furthest away from and below benchmark, and phase 2 targeted all remaining individuals below benchmark.

A similar review of FTEs (based on required number of shifts for a full-time hospitalist) tied to our internal DHM leadership positions was completed by the division head and director of DEI. Specifically, the mission for each of our internally funded roles, job descriptions, and responsibilities was reviewed to ensure equity in funding.

Recruitment and advancement: processes to ensure equity and diversity in recruitment, tracking, and reporting, working to eliminate/mitigate bias. In collaboration with members of the AAMC Group on Women in Medicine and Science (GWIMS) and coauthors from various institutions, we developed toolkits and checklists aimed at achieving equity and diversity within candidate pools and on major committees, including, but not limited to, search and promotion committees.³² Additionally, a checklist was developed to help recruit more diverse speakers, including women and URMs, for local, regional, and national conferences.

Policies: evidence-based approaches, tracking and reporting, standardized approaches to eliminate/mitigate bias, embracing nontraditional paths. In partnership with our departmental efforts, members of our team led data collection and reporting for salary benchmarking, leadership roles, and committee membership. This included developing surveys and reporting templates that can be used to identify disparities and inform future efforts. We worked to ensure that we have faculty representing our field at the department and SOM levels. Specifically, we made sure to nominate division members during open calls for departmental and schoolwide committees, including the promotions committee.

Our People

The faculty and staff within our division have been instrumental in moving efforts forward in the following important areas.

Leadership: develop the position of director of DEI as well as leadership structures to support and increase DEI. One of the first steps in our strategic plan was creating a director of DEI leadership role (Appendix Figure 2). The director is responsible for researching, applying, and promoting a broad scope of DEI initiatives and best practices within the DHM, DOM, and SOM (in collaboration with their leaders), including recruitment, retention, and promotion of medical students, residents, and faculty; educational program development; health disparities research; and community-engaged scholarship.

Support: develop family leave policies/develop flexible work policies. Several members of our division worked on departmental committees and served in leadership roles on staff and faculty council. Estimated costs were assessed. Through collective efforts of department leadership and division head support, the department approved parental leave to employees following the birth of an employee’s child or the placement of a child with an employee in connection with adoption or permanent foster care.

Mentorship/sponsorship: enhance faculty advancement programs/develop pipeline and trainings/collaborate with student groups and organizations/invest in all of our people. Faculty across our divisional sites have held important roles in developing pipeline programs for undergraduate students bound for health professions, as well as programs developed specifically for medical students and internal medicine residents. This includes two programs, the CU Hospitalist Scholars Program (CUHSP) and Leadership Education for Aspiring Doctors (LEAD), in which undergraduate students have the opportunity to round with hospital medicine teams, work on quality-improvement projects, and receive extensive mentorship and advising from a diverse faculty team. Additionally, our faculty advancement team within the DHM has grown and been restructured to include more defined goals and to ensure each faculty member has at least one mentor in their area of interest.

Supportive: lactation space and support/diverse space options/inclusive and diverse environments. We worked closely with hospital leadership to advocate for adequately equipped lactation spaces, including equipment such as pumps, refrigerators, and computer workstations. Additionally, our team members conducted environmental scans (eg, identified pictures, artwork, or other images that were not representative of a diverse and inclusive environment and raised concerns when the environment was not inclusive).

Measures

Our measures focused on (1) development and implementation of our DEI strategic plan, including new policies, processes, and practices related to key components of the DEI program; and (2) assessment of specific DEI programs, including pre-post salary data disparities based on rank and pre-post disparities for protected time for similar roles.

Analysis

Through rapid PDSA cycles, we evaluated salary equity, equity in leadership allotment, and committee membership. We have developed a tracking board to track progress of the multiple projects in the strategic plan.

Strategic Plan Development and Tracking

From October 2017 to December 2018, we developed a robust strategic plan and stepwise approach to DEI (Figure 1 and Figure 2). The director of DEI position was developed (see Appendix Figure 2 for job description) to help oversee these efforts. Figure 3 highlights the specific efforts and the progress made on implementation (ie, high-level dashboard or “tracking board”). While outcomes are still pending in the areas of recruitment and advancement and environment, we have made measurable improvements in compensation, as outlined in the following section.

Compensation

One year after the salary-equity interventions, all of our physician faculty’s salaries were at the goal benchmark (Table), and differences in salary for those in similar years of rank were nearly eliminated. Similarly, after implementing an internally consistent approach to assigning FTE for new and established positions within the division (ie, those that fall within the purview of the division), all faculty in similar types of roles had similar amounts of protected time.

Recruitment and Advancement

Toolkits³² and committee recommendations have been incorporated into division goals, though some aspects are still in implementation phases, as division-wide implicit bias training was delayed secondary to the COVID-19 pandemic. Key goals include: (1) implicit bias training for all members of major committees; (2) aiming for a goal of at least 40% representation of women and 40% URMs on committees; (3) having a diversity expert serve on each committee in order to identify and discuss any potential bias in the search and candidate-selection processes; and (4) careful tracking of diversity metrics in regard to diversity of candidates at each step of the interview and selection process.

Surveys and reporting templates for equity on committees and leadership positions have been developed and deployed. Data dashboards for our division have been developed as well (for compensation, leadership, and committee membership). A divisional dashboard to report recruitment efforts is in progress.

We have successfully nominated several faculty members to the SOM promotions committee and departmental committees during open calls for these positions. At the division level, we have also adapted internal policies to ensure promotion occurs on time and offers alternative pathways for faculty that may primarily focus on clinical pathways. All faculty who have gone up for promotion thus far have been successfully promoted in their desired pathway.

Environment

We successfully advocated and achieved adequately equipped lactation spaces, including equipment such as pumps, refrigerators, and computer workstations. This achievement was possible because of our hospital partners. Our efforts helped us acquire sufficient space and facilities such that nursing mothers can pump and still be able to answer phones, enter orders, and document visits.

Our team members conducted environmental scans and raised concerns when the environment was not inclusive, such as conference rooms with portraits of leadership that do not show diversity. The all-male pictures were removed from one frequently used departmental conference room, which will eventually house a diverse group of pictures and achievements.

We aim to eliminate bias by offering implicit bias training for our faculty. While this is presently required for those who serve on committees, in leadership positions, or those involved in recruitment and interviewing for the DOM, our goal is to eventually provide this training to all faculty and staff in the division. We have also incorporated DEI topics into our educational conferences for faculty, including sessions on recognizing bias in medicine, how to be an upstander/ally, and the impact of race and racism on medicine.

DISCUSSION

The important findings of this work are: (1) that successes in DEI can be achieved with strategic planning and stakeholder engagement; (2) through simple modification of processes, we can improve equity in compensation and FTE allotted to leadership; (3) though it takes time, diversity recruitment can be improved using sound, sustainable, evidence-based processes; (4) this work is time-intensive and challenging, requiring ongoing efforts to improve, modify, and enhance current efforts and future successes.

We have certainly made some progress with DEI initiatives within our division and have also learned a great deal from this experience. First, change is difficult for all parties involved, including those leading change and those affected by the changes. We purposely made an effort to facilitate discussions with all of the DHM faculty and staff to ensure that everyone felt included in this work and that everyone’s voice was heard. This was exemplified by inviting all faculty members to a feedback session in which we discussed DEI within our division and areas that we wanted to improve on. Early on, we were able to define what diversity, equity, and inclusion meant to us as a division and then use these definitions to develop tangible goals for all the areas of highest importance to the group.

By increasing faculty presence on key committees, such as the promotions committee, we now have faculty members who are well versed in promotions processes. We are fortunate to have a promotions process that supports faculty advancement for faculty with diverse interests that spans from supporting highly clinical faculty, clinician educators, as well as more traditional researchers.³⁴ By having hospitalists serve in these roles, we help to add to the diverse perspectives on these committees, including emphasizing the scholarship that is associated with quality improvement, as well as DEI efforts which can often be viewed as service as opposed to scholarship.

Clear communication and transparency were key to all of our DEI initiatives. We had monthly updates on our DEI efforts during business meetings and also held impromptu meetings (also known as flash mobs³⁵) to answer questions and discuss concerns in real time. As with all DEI work, it is important to know where you are starting (having accurate data and a clear understanding of the data) and be able to communicate that data to the group. For example, using AAMC salary benchmarking³³ as well as other benchmarks allowed us to accurately calculate variance among salaries and identify the appropriate goal salary for each of our faculty members. Likewise, by completing an in-depth inventory on the work being done by all of our faculty in leadership roles, we were able to standardize the compensation/FTE for each of these roles. Tracking these changes over time, via the use of dashboards in our case, allows for real-time measurements and accountability for all of those involved. Our end goal will be to have all of these initiatives feed into one large dashboard.

Collaborating with leadership and stakeholders in the DOM, SOM, and hospital helped to make our DEI initiatives successful. Much too often, we work in silos when it comes to DEI work. However, we tend to have similar goals and can achieve much more if we work together. Collaboration with multiple stakeholders allowed for wider dissemination and resulted in a larger impact to the campus and community at large. This has been exemplified by the committee composition guidance that has been utilized by the DOM, as well as implementation of campus-wide policies, specifically the parental leave policy, which our faculty members played an important role in creating. Likewise, it is important to look outside of our institutions and work with other hospital medicine groups around the country who are interested in promoting DEI.

We still have much work ahead of us. We are continuing to measure outcomes status postimplementation of the toolkit and checklists being used for diversity recruitment and committee composition. Additionally, we are actively working on several initiatives, including:

• Instituting implicit bias training for all of our faculty
• Partnering with national leaders and our hospital systems to develop zero-tolerance policies regarding abusive behaviors (verbal, physical, and other), racism, and sexism in the hospital and other work settings
• Development of specific recruitment strategies as a means of diversifying our healthcare workforce (of note, based on a 2020 survey of our faculty, in which there was a 70% response rate, 8.5% of our faculty identified as URMs)
• Completion of a diversity dashboard to track our progress in all of these efforts over time
• Development of a more robust pipeline to promotion and leadership for our URM faculty

This study has several strengths. Many of the plans and strategies described here can be used to guide others interested in implementing this work. Figure 2 provides a stepwise
approach to addressing DEI in hospital medicine groups and divisions. We conducted this work at a large academic medical center, and while it may not be generalizable, it does offer some ideas for others to consider in their own work to advance DEI at their institutions. There are also several limitations to this work. Eliminating salary inequities with our approach did take resources. We took advantage of already lower salaries and the need to increase salaries closer to benchmark and paired this effort with our DEI efforts to achieve salary equity. This required partnerships with the department and hospital. Efforts to advance DEI also take a lot of time and effort, and thus commitment from the division, department, and institution as a whole is key. While we have outcomes for our efforts related to salary equity, recruitment efforts should be realized over time, as currently it is too early to tell. We have highlighted the efforts that have been put in place at this time.

Using a systematic evidence-based approach with key stakeholder involvement, a division-wide DEI strategy was developed and implemented. While this work is still ongoing, short-term wins are possible, in particular around salary equity and development of policies and structures to promote DEI.

Despite recent advances made in medicine, gender-based disparities persist.^1-3 In particular, women with children have barriers to career advancement and show evidence of slower career advancement.^1,2 Multiple challenges for working women experiencing motherhood have been described. In academic medicine in the United States, women have limited access to paid parental leave.^4-6 For women who choose to breastfeed, there is limited time, space, and support available for breastfeeding.⁷ Furthermore, sleep deprivation in the postpartum period significantly impacts the ability to function at work.⁸

Hospital medicine is a unique specialty as it comprises 47% women, 80% of whom are aged less than 40 years, suggesting that a large portion are women of childbearing age.⁹ The field poses known challenges to this population, including shift work, atypical schedules, and unpredictable hours. We conducted a descriptive qualitative study to improve our understanding of the experience of female academic hospitalists who have experienced pregnancy, parental leave, and the return to work as faculty. Our goal was to both explore the challenges to undergoing this experience and discover solutions to support female academic hospitalists.

Study Design

We conducted a qualitative descriptive study of female hospitalists recruited from academic institutions represented in Society of Hospital Medicine (SHM) committees. Interviews were conducted between November 2017 and February 2018. Participants completed an informed consent and a demographic survey prior to the interview. Each interview lasted approximately 30 minutes; discussions were recorded on digital records and transcribed verbatim. This protocol was reviewed and granted exemption by the Institutional Review Board at the University of Colorado.

Population

We recruited participants from a selection of hospital medicine groups nationally, chosen from SHM committee representation. A purposeful snowball approach was used to identify hospitalists from representative programs and seek their recommendation for hospitalists from other targeted programs. Ten hospitalists were approached by e-mail to determine their interest in participation, and all of them agreed to participate. Each participant experienced new parenthood within the last seven years.

Framework

We constructed our interview to represent the following timeline associated with having children as it pertains to a hospitalist position: pregnancy, parental leave, and the return to work. The interview guide was structured to invoke the positive aspects, challenges, and solutions within each domain (Appendix 1).

Analysis

Codes were inductively developed from the interview data by a team of three board-certified internal medicine physicians (E.G., A.M., and C.J.), one of whom had prior training and experience with qualitative interviews and analysis (C.J.). Among the coders, two (E.G. and A.M.) conducted the semistructured interviews. Code disparities were reconciled by team consensus, where the primary coder facilitated the discussions. Themes were developed inductively from the codes, and the analysis was completed using a team-based iterative approach that was facilitated using ATLAS.ti.¹⁰ Thematic saturation was achieved. This study was approved by the Colorado Multiple Institutional Review Board.

The demographics and the characteristics of the hospital medicine group are shown in Table 1. Although we asked questions about both the positive and challenging aspects of the experience of parenthood, the interviews tended to focus more on the challenges faced and on areas for optimization.

Paid Parental leave

Most of the participants described inadequate paid parental leave, with minimal transparency in the processes for ensuring time off following the birth of their child, resulting in “haggling” with bosses, human resources, and the administrative staff. Rarely was a formal parental leave policy in place. Once a parental leave plan was established, several women reported the financial burden associated with a leave that was partially, or fully, unpaid.

“All of my leave was unpaid. .. managed to finagle short-term disability into paying for it… the system was otherwise set up to screw me financially.”

For the three women who did experience sufficient paid parental leave, they recognized the financial and emotional benefit and suggested that further optimization would include a prebirth schedule to account for the physical challenges and potential complications.

Physical Challenges

All of the women described significant physical challenges when working during pregnancy, resulting in limited bandwidth for additional academic activities outside of direct clinical care responsibilities.

“Exhaustion that hits you in your pregnancy and then you have to round. I used to lie on the floor of my office, take a little nap, wake up, write some notes, go home, take another nap, wake up, write some more notes.”

Upon return to work, women reported additional physical challenges related to sleep deprivation, impacting their productivity with academic work and emotional well-being.

“I came back from maternity leave and I was sleep-deprived and exhausted, I didn’t have the energy. All of these great projects that I had started or dreamed of … dwindled and died on the vine.”

Solutions suggested by the participants included creation of a flexible schedule with a ramp-up and ramp-down period around the birth.

Breastfeeding

The majority of participants in this study encountered several challenges associated with a shared goal of breastfeeding according to evidence-based guidelines.¹¹ Designated pumping areas were often inconveniently located and not conducive to multitasking.

“It’s two chairs that are behind a curtain in a women’s locker room in the basement of the hospital, that are tiny and gross. No computers, so I felt like I was wasting time.”

One hospitalist described carving out time for pumping in her office while multitasking with clinical work.

“I would get to work, set up, and pump while chart reviewing. Then I would go and see people… and come back to my office and pump and write a few notes. And go out and see more patients, and then pump and write a few more notes. And then pump, and then go home. I was like a cow.”

Women highlighted the barriers that could be optimized such as creating time in the clinical schedule for pumping, a physical space to breastfeed or pump, and accessible milk storage facilities.

Career Opportunities

When asked about the impact of parental leave on career opportunities, a few of the women described a phenomenon of no longer being asked to participate or being left out of prior projects.

“People didn’t want to offer you things or give you things because they realize you’re having this transition in your life. Not out of animosity, but out of courtesy that they don’t want to fill up your place even more. Her plate is full; we are not going to ask her to do anything extra.”

However, two women specifically reported a supportive environment without a loss of opportunities, often referenced as a boss who “saved” projects for their return.

Colleague Responses

One participant used the term “microaggressions,” to describe passive aggressions encountered by their colleagues or leadership.

“(A colleague) was diagnosed with pre-eclampsia, and very urgently had to deliver and couldn’t cover a week of shifts…She was asked initially to find her own coverage…Not treating (pregnancy) similar to other serious illnesses is what I would term a microaggression.”

Yet, women in our study also reported positive responses from colleagues and the importance of support networks of physician mothers (Table 2).

Empathy in Patient Care

Finally, the experience of motherhood impacted all of the women as physicians, described as increased empathy, patience, and understanding of difficult family situations.

“I’m just more sensitive to people’s lives outside the hospital, so, you know, when it’s difficult for a family member to get there because they have three other kids they are taking care of or, somebody that says they are leaving AMA, but it’s because they have a sick kid at home. I just have a better context for that.”

Gender disparities persist in both internal medicine and hospital medicine.¹ Providers in this descriptive qualitative study suggested that the following factors contribute: lack of paid parental leave and the associated financial penalties, loss of career opportunities, the physical challenges associated with pregnancy, decreasing productivity, and the amount of time and effort involved in breastfeeding. However, the participants also shared valuable ideas for future solutions to relieve the challenges imposed on working physician mothers (Table 2).

Breaking the Glass Ceiling

Participants noted the importance of a paid leave policy that encompasses not only maternity leave but also a flexible scheduling period before and after the leave to account for the challenges of pregnancy and new motherhood. Paid parental leave is rare in academic settings, but studies from other industries show that when women take paid leave, they are more likely to remain in the workforce 9-12 months afterward, work more weekly hours, and feel more loyal to their organization.^12,13 In the rare instance when negotiations around leave violate local policy or the law, women should be encouraged to seek guidance from their human resources department.

Me Too: Building Solidarity

Women in our study reported the value of a supportive workplace in easing their transition into motherhood. Specifically, they noted that a supportive boss who protected their career opportunities prevented momentum loss in their career trajectory. Access to mutual supports such as the Physicians Mom Group, a well-established Facebook group comprising more than 70,000 women, was referenced as a meaningful way to share joys and tribulations related to balancing a career as a physician and motherhood. Growth of similar support systems within institutions will further support this experience.

Time’s Up: The Promotion Clock

Women in our study described a prolonged period of diminished productivity related to having children, coinciding with a set time to promotion in academics. Flexible promotion schedules may impact women’s ability to successfully undergo promotion.

The aim of this study was to represent a shared set of experiences of female academic hospitalists who participated; therefore, the results may not be generalizable beyond this group. Due to the use of a purposeful snowball approach, there was a potential for selection bias. Future research may include comparing the experience of women at institutions that offer paid leave versus those that do not and the impact on retention, promotion, and well-being.

Women in hospital medicine encounter several challenges to having children, but they are also motivated to provide solutions. Efforts to improve the institutional and cultural landscape to better support women physicians with children are critical to prevent attrition of women and ensure equitable academic promotion and achievement of leadership positions.

Disclosures

The authors have no conflicts of interest to report.

Author Contributions

Each author was involved in the creation of the study protocol, data collection and analysis, and creation of the manuscript.

Despite recent advances made in medicine, gender-based disparities persist.^1-3 In particular, women with children have barriers to career advancement and show evidence of slower career advancement.^1,2 Multiple challenges for working women experiencing motherhood have been described. In academic medicine in the United States, women have limited access to paid parental leave.^4-6 For women who choose to breastfeed, there is limited time, space, and support available for breastfeeding.⁷ Furthermore, sleep deprivation in the postpartum period significantly impacts the ability to function at work.⁸

Hospital medicine is a unique specialty as it comprises 47% women, 80% of whom are aged less than 40 years, suggesting that a large portion are women of childbearing age.⁹ The field poses known challenges to this population, including shift work, atypical schedules, and unpredictable hours. We conducted a descriptive qualitative study to improve our understanding of the experience of female academic hospitalists who have experienced pregnancy, parental leave, and the return to work as faculty. Our goal was to both explore the challenges to undergoing this experience and discover solutions to support female academic hospitalists.

Study Design

We conducted a qualitative descriptive study of female hospitalists recruited from academic institutions represented in Society of Hospital Medicine (SHM) committees. Interviews were conducted between November 2017 and February 2018. Participants completed an informed consent and a demographic survey prior to the interview. Each interview lasted approximately 30 minutes; discussions were recorded on digital records and transcribed verbatim. This protocol was reviewed and granted exemption by the Institutional Review Board at the University of Colorado.

Population

We recruited participants from a selection of hospital medicine groups nationally, chosen from SHM committee representation. A purposeful snowball approach was used to identify hospitalists from representative programs and seek their recommendation for hospitalists from other targeted programs. Ten hospitalists were approached by e-mail to determine their interest in participation, and all of them agreed to participate. Each participant experienced new parenthood within the last seven years.

Framework

We constructed our interview to represent the following timeline associated with having children as it pertains to a hospitalist position: pregnancy, parental leave, and the return to work. The interview guide was structured to invoke the positive aspects, challenges, and solutions within each domain (Appendix 1).

Analysis

Codes were inductively developed from the interview data by a team of three board-certified internal medicine physicians (E.G., A.M., and C.J.), one of whom had prior training and experience with qualitative interviews and analysis (C.J.). Among the coders, two (E.G. and A.M.) conducted the semistructured interviews. Code disparities were reconciled by team consensus, where the primary coder facilitated the discussions. Themes were developed inductively from the codes, and the analysis was completed using a team-based iterative approach that was facilitated using ATLAS.ti.¹⁰ Thematic saturation was achieved. This study was approved by the Colorado Multiple Institutional Review Board.

The demographics and the characteristics of the hospital medicine group are shown in Table 1. Although we asked questions about both the positive and challenging aspects of the experience of parenthood, the interviews tended to focus more on the challenges faced and on areas for optimization.

Paid Parental leave

Most of the participants described inadequate paid parental leave, with minimal transparency in the processes for ensuring time off following the birth of their child, resulting in “haggling” with bosses, human resources, and the administrative staff. Rarely was a formal parental leave policy in place. Once a parental leave plan was established, several women reported the financial burden associated with a leave that was partially, or fully, unpaid.

“All of my leave was unpaid. .. managed to finagle short-term disability into paying for it… the system was otherwise set up to screw me financially.”

For the three women who did experience sufficient paid parental leave, they recognized the financial and emotional benefit and suggested that further optimization would include a prebirth schedule to account for the physical challenges and potential complications.

Physical Challenges

All of the women described significant physical challenges when working during pregnancy, resulting in limited bandwidth for additional academic activities outside of direct clinical care responsibilities.

“Exhaustion that hits you in your pregnancy and then you have to round. I used to lie on the floor of my office, take a little nap, wake up, write some notes, go home, take another nap, wake up, write some more notes.”

Upon return to work, women reported additional physical challenges related to sleep deprivation, impacting their productivity with academic work and emotional well-being.

“I came back from maternity leave and I was sleep-deprived and exhausted, I didn’t have the energy. All of these great projects that I had started or dreamed of … dwindled and died on the vine.”

Solutions suggested by the participants included creation of a flexible schedule with a ramp-up and ramp-down period around the birth.

Breastfeeding

The majority of participants in this study encountered several challenges associated with a shared goal of breastfeeding according to evidence-based guidelines.¹¹ Designated pumping areas were often inconveniently located and not conducive to multitasking.

“It’s two chairs that are behind a curtain in a women’s locker room in the basement of the hospital, that are tiny and gross. No computers, so I felt like I was wasting time.”

One hospitalist described carving out time for pumping in her office while multitasking with clinical work.

“I would get to work, set up, and pump while chart reviewing. Then I would go and see people… and come back to my office and pump and write a few notes. And go out and see more patients, and then pump and write a few more notes. And then pump, and then go home. I was like a cow.”

Women highlighted the barriers that could be optimized such as creating time in the clinical schedule for pumping, a physical space to breastfeed or pump, and accessible milk storage facilities.

Career Opportunities

When asked about the impact of parental leave on career opportunities, a few of the women described a phenomenon of no longer being asked to participate or being left out of prior projects.

“People didn’t want to offer you things or give you things because they realize you’re having this transition in your life. Not out of animosity, but out of courtesy that they don’t want to fill up your place even more. Her plate is full; we are not going to ask her to do anything extra.”

However, two women specifically reported a supportive environment without a loss of opportunities, often referenced as a boss who “saved” projects for their return.

Colleague Responses

One participant used the term “microaggressions,” to describe passive aggressions encountered by their colleagues or leadership.

“(A colleague) was diagnosed with pre-eclampsia, and very urgently had to deliver and couldn’t cover a week of shifts…She was asked initially to find her own coverage…Not treating (pregnancy) similar to other serious illnesses is what I would term a microaggression.”

Yet, women in our study also reported positive responses from colleagues and the importance of support networks of physician mothers (Table 2).

Empathy in Patient Care

Finally, the experience of motherhood impacted all of the women as physicians, described as increased empathy, patience, and understanding of difficult family situations.

“I’m just more sensitive to people’s lives outside the hospital, so, you know, when it’s difficult for a family member to get there because they have three other kids they are taking care of or, somebody that says they are leaving AMA, but it’s because they have a sick kid at home. I just have a better context for that.”

Gender disparities persist in both internal medicine and hospital medicine.¹ Providers in this descriptive qualitative study suggested that the following factors contribute: lack of paid parental leave and the associated financial penalties, loss of career opportunities, the physical challenges associated with pregnancy, decreasing productivity, and the amount of time and effort involved in breastfeeding. However, the participants also shared valuable ideas for future solutions to relieve the challenges imposed on working physician mothers (Table 2).

Breaking the Glass Ceiling

Participants noted the importance of a paid leave policy that encompasses not only maternity leave but also a flexible scheduling period before and after the leave to account for the challenges of pregnancy and new motherhood. Paid parental leave is rare in academic settings, but studies from other industries show that when women take paid leave, they are more likely to remain in the workforce 9-12 months afterward, work more weekly hours, and feel more loyal to their organization.^12,13 In the rare instance when negotiations around leave violate local policy or the law, women should be encouraged to seek guidance from their human resources department.

Me Too: Building Solidarity

Women in our study reported the value of a supportive workplace in easing their transition into motherhood. Specifically, they noted that a supportive boss who protected their career opportunities prevented momentum loss in their career trajectory. Access to mutual supports such as the Physicians Mom Group, a well-established Facebook group comprising more than 70,000 women, was referenced as a meaningful way to share joys and tribulations related to balancing a career as a physician and motherhood. Growth of similar support systems within institutions will further support this experience.

Time’s Up: The Promotion Clock

Women in our study described a prolonged period of diminished productivity related to having children, coinciding with a set time to promotion in academics. Flexible promotion schedules may impact women’s ability to successfully undergo promotion.

The aim of this study was to represent a shared set of experiences of female academic hospitalists who participated; therefore, the results may not be generalizable beyond this group. Due to the use of a purposeful snowball approach, there was a potential for selection bias. Future research may include comparing the experience of women at institutions that offer paid leave versus those that do not and the impact on retention, promotion, and well-being.

Women in hospital medicine encounter several challenges to having children, but they are also motivated to provide solutions. Efforts to improve the institutional and cultural landscape to better support women physicians with children are critical to prevent attrition of women and ensure equitable academic promotion and achievement of leadership positions.

Disclosures

The authors have no conflicts of interest to report.

Author Contributions

Each author was involved in the creation of the study protocol, data collection and analysis, and creation of the manuscript.

Despite recent advances made in medicine, gender-based disparities persist.^1-3 In particular, women with children have barriers to career advancement and show evidence of slower career advancement.^1,2 Multiple challenges for working women experiencing motherhood have been described. In academic medicine in the United States, women have limited access to paid parental leave.^4-6 For women who choose to breastfeed, there is limited time, space, and support available for breastfeeding.⁷ Furthermore, sleep deprivation in the postpartum period significantly impacts the ability to function at work.⁸

Hospital medicine is a unique specialty as it comprises 47% women, 80% of whom are aged less than 40 years, suggesting that a large portion are women of childbearing age.⁹ The field poses known challenges to this population, including shift work, atypical schedules, and unpredictable hours. We conducted a descriptive qualitative study to improve our understanding of the experience of female academic hospitalists who have experienced pregnancy, parental leave, and the return to work as faculty. Our goal was to both explore the challenges to undergoing this experience and discover solutions to support female academic hospitalists.

Study Design

We conducted a qualitative descriptive study of female hospitalists recruited from academic institutions represented in Society of Hospital Medicine (SHM) committees. Interviews were conducted between November 2017 and February 2018. Participants completed an informed consent and a demographic survey prior to the interview. Each interview lasted approximately 30 minutes; discussions were recorded on digital records and transcribed verbatim. This protocol was reviewed and granted exemption by the Institutional Review Board at the University of Colorado.

Population

We recruited participants from a selection of hospital medicine groups nationally, chosen from SHM committee representation. A purposeful snowball approach was used to identify hospitalists from representative programs and seek their recommendation for hospitalists from other targeted programs. Ten hospitalists were approached by e-mail to determine their interest in participation, and all of them agreed to participate. Each participant experienced new parenthood within the last seven years.

Framework

We constructed our interview to represent the following timeline associated with having children as it pertains to a hospitalist position: pregnancy, parental leave, and the return to work. The interview guide was structured to invoke the positive aspects, challenges, and solutions within each domain (Appendix 1).

Analysis

Codes were inductively developed from the interview data by a team of three board-certified internal medicine physicians (E.G., A.M., and C.J.), one of whom had prior training and experience with qualitative interviews and analysis (C.J.). Among the coders, two (E.G. and A.M.) conducted the semistructured interviews. Code disparities were reconciled by team consensus, where the primary coder facilitated the discussions. Themes were developed inductively from the codes, and the analysis was completed using a team-based iterative approach that was facilitated using ATLAS.ti.¹⁰ Thematic saturation was achieved. This study was approved by the Colorado Multiple Institutional Review Board.

The demographics and the characteristics of the hospital medicine group are shown in Table 1. Although we asked questions about both the positive and challenging aspects of the experience of parenthood, the interviews tended to focus more on the challenges faced and on areas for optimization.

Paid Parental leave

Most of the participants described inadequate paid parental leave, with minimal transparency in the processes for ensuring time off following the birth of their child, resulting in “haggling” with bosses, human resources, and the administrative staff. Rarely was a formal parental leave policy in place. Once a parental leave plan was established, several women reported the financial burden associated with a leave that was partially, or fully, unpaid.

“All of my leave was unpaid. .. managed to finagle short-term disability into paying for it… the system was otherwise set up to screw me financially.”

For the three women who did experience sufficient paid parental leave, they recognized the financial and emotional benefit and suggested that further optimization would include a prebirth schedule to account for the physical challenges and potential complications.

Physical Challenges

All of the women described significant physical challenges when working during pregnancy, resulting in limited bandwidth for additional academic activities outside of direct clinical care responsibilities.

“Exhaustion that hits you in your pregnancy and then you have to round. I used to lie on the floor of my office, take a little nap, wake up, write some notes, go home, take another nap, wake up, write some more notes.”

Upon return to work, women reported additional physical challenges related to sleep deprivation, impacting their productivity with academic work and emotional well-being.

“I came back from maternity leave and I was sleep-deprived and exhausted, I didn’t have the energy. All of these great projects that I had started or dreamed of … dwindled and died on the vine.”

Solutions suggested by the participants included creation of a flexible schedule with a ramp-up and ramp-down period around the birth.

Breastfeeding

The majority of participants in this study encountered several challenges associated with a shared goal of breastfeeding according to evidence-based guidelines.¹¹ Designated pumping areas were often inconveniently located and not conducive to multitasking.

“It’s two chairs that are behind a curtain in a women’s locker room in the basement of the hospital, that are tiny and gross. No computers, so I felt like I was wasting time.”

One hospitalist described carving out time for pumping in her office while multitasking with clinical work.

“I would get to work, set up, and pump while chart reviewing. Then I would go and see people… and come back to my office and pump and write a few notes. And go out and see more patients, and then pump and write a few more notes. And then pump, and then go home. I was like a cow.”

Women highlighted the barriers that could be optimized such as creating time in the clinical schedule for pumping, a physical space to breastfeed or pump, and accessible milk storage facilities.

Career Opportunities

When asked about the impact of parental leave on career opportunities, a few of the women described a phenomenon of no longer being asked to participate or being left out of prior projects.

“People didn’t want to offer you things or give you things because they realize you’re having this transition in your life. Not out of animosity, but out of courtesy that they don’t want to fill up your place even more. Her plate is full; we are not going to ask her to do anything extra.”

However, two women specifically reported a supportive environment without a loss of opportunities, often referenced as a boss who “saved” projects for their return.

Colleague Responses

One participant used the term “microaggressions,” to describe passive aggressions encountered by their colleagues or leadership.

“(A colleague) was diagnosed with pre-eclampsia, and very urgently had to deliver and couldn’t cover a week of shifts…She was asked initially to find her own coverage…Not treating (pregnancy) similar to other serious illnesses is what I would term a microaggression.”

Yet, women in our study also reported positive responses from colleagues and the importance of support networks of physician mothers (Table 2).

Empathy in Patient Care

Finally, the experience of motherhood impacted all of the women as physicians, described as increased empathy, patience, and understanding of difficult family situations.

“I’m just more sensitive to people’s lives outside the hospital, so, you know, when it’s difficult for a family member to get there because they have three other kids they are taking care of or, somebody that says they are leaving AMA, but it’s because they have a sick kid at home. I just have a better context for that.”

Gender disparities persist in both internal medicine and hospital medicine.¹ Providers in this descriptive qualitative study suggested that the following factors contribute: lack of paid parental leave and the associated financial penalties, loss of career opportunities, the physical challenges associated with pregnancy, decreasing productivity, and the amount of time and effort involved in breastfeeding. However, the participants also shared valuable ideas for future solutions to relieve the challenges imposed on working physician mothers (Table 2).

Breaking the Glass Ceiling

Participants noted the importance of a paid leave policy that encompasses not only maternity leave but also a flexible scheduling period before and after the leave to account for the challenges of pregnancy and new motherhood. Paid parental leave is rare in academic settings, but studies from other industries show that when women take paid leave, they are more likely to remain in the workforce 9-12 months afterward, work more weekly hours, and feel more loyal to their organization.^12,13 In the rare instance when negotiations around leave violate local policy or the law, women should be encouraged to seek guidance from their human resources department.

Me Too: Building Solidarity

Women in our study reported the value of a supportive workplace in easing their transition into motherhood. Specifically, they noted that a supportive boss who protected their career opportunities prevented momentum loss in their career trajectory. Access to mutual supports such as the Physicians Mom Group, a well-established Facebook group comprising more than 70,000 women, was referenced as a meaningful way to share joys and tribulations related to balancing a career as a physician and motherhood. Growth of similar support systems within institutions will further support this experience.

Time’s Up: The Promotion Clock

Women in our study described a prolonged period of diminished productivity related to having children, coinciding with a set time to promotion in academics. Flexible promotion schedules may impact women’s ability to successfully undergo promotion.

The aim of this study was to represent a shared set of experiences of female academic hospitalists who participated; therefore, the results may not be generalizable beyond this group. Due to the use of a purposeful snowball approach, there was a potential for selection bias. Future research may include comparing the experience of women at institutions that offer paid leave versus those that do not and the impact on retention, promotion, and well-being.

Women in hospital medicine encounter several challenges to having children, but they are also motivated to provide solutions. Efforts to improve the institutional and cultural landscape to better support women physicians with children are critical to prevent attrition of women and ensure equitable academic promotion and achievement of leadership positions.

Disclosures

The authors have no conflicts of interest to report.

Author Contributions

Each author was involved in the creation of the study protocol, data collection and analysis, and creation of the manuscript.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Is fondaparinux as safe and effective as argatroban and danaparoid in treating heparin-induced thrombocytopenia (HIT)?

Background: Guidelines for the treatment of HIT recommend using danaparoid (factor Xa inhibitor), argatroban, or lepirudin (both direct thrombin inhibitors). Reduced availability, cost, and complexity of administration limit these options, and fondaparinux is often used off label in the treatment of HIT.

Study design: Retrospective cohort study.

Setting: London Health Sciences Centre, Ontario, Canada.

Synopsis: Investigators analyzed 133 patients receiving fondaparinux for HIT against unmatched (n=106) and matched (n=60) cohorts receiving either argatroban or danaparoid. Using a composite of new thrombotic events, amputation, gangrene, thrombosis-related death, or death in which thrombosis cannot be excluded as the primary outcome, there was no difference between fondaparinux (16.5%) and the unmatched (19.8%) or matched (16.5%) cohorts of argatroban/danaparoid.

There also was no difference in major bleeding events between fondaparinux (21.1%) and the unmatched (25.5%) and matched (20.0%) argatroban/danaparoid cohorts, though major bleeding rates in this group were higher than in other studies, possibly reflecting a greater proportion of patients with renal dysfunction.

The single-site study was underpowered, and generalizability is limited, as the authors could not review all potential patient files. The risk of confounding effects is increased in the absence of randomization and universal gold standard confirmatory testing among the cohort. Prospective trials are needed to establish the safety and efficacy of treating HIT with fondaparinux.

Bottom line: In this underpowered and retrospective cohort study, fondaparinux was as effective in treating HIT as argatroban and danaparoid, with a similar safety profile.

Citation: Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015;125(6):924-929.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Does the presence of a rapid response team (RRT) affect the perception of resident education and autonomy?

Background: Studies on the perception of RRTs, which can generally be activated by any concerned staff member, have been primarily limited to nurses. No studies to date have evaluated resident perception of the effects of RRTs on education or autonomy.

Study design: Survey study measure on a five-point Likert scale.

Setting: Moffitt-Long Hospital, a 600-bed acute care hospital and tertiary academic medical center of the University of California San Francisco.

Synopsis: Among 342 potential respondents, 246 surveys were completed, 10 of which were excluded due a lack of experience with RRTs. Overall, 78% of respondents felt that working with RRTs creates a valuable educational experience, though this was seen more commonly in the responses of medical residents (83.2%) than in those of surgical residents (70.4%). There was no significant difference between interns (82.9%) and upper-level residents (77.3%).

Additionally, 75.8% of respondents did not feel that the presence of an RRT decreased resident autonomy, and there was no statistically significant difference between the responses of interns (77.8%) and upper-level residents (76.8%), or between those of medical (79.9%) and surgical (71.2%) residents.

The survey design increases the risk of response bias, and the single-site nature limits generalizability. Additionally, no objective measurements of education or autonomy were evaluated.

Bottom line: The presence of RRTs is perceived as having educational value and is not perceived by residents as reducing resident autonomy.

Citation: Butcher BW, Quist CE, Harrison JD, Ranji SR. The effect of a rapid response team on resident perceptions of education and autonomy. J Hosp Med. 2015;10(1):8-12.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Do individual provider feedback and a pay-for-performance incentive program improve the use of guideline-compliant VTE prophylaxis?

Background: The appropriate use of VTE prophylaxis is a Joint Commission core measure set, a publicly reported performance metric for quality care, and part of the hospital value-based purchasing component of healthcare reform. Despite guidelines on effective and safe measures to prevent VTE, compliance rates are often below 50%.

Study design: Retrospective analysis.

Setting: Academic hospitalists at a tertiary care medical center.

Synopsis: Using a web-based, transparent dashboard and a pay-for-performance program with graduated payouts, this analysis showed a significant improvement in VTE compliance rates by providers. Specifically, the combination of both interventions yielded the highest rate. The monthly compliance rate increased from a baseline of 86% (95% confidence interval [CI], 85-88%) to 90% (95% CI, 88-93%) with the dashboard alone (P=0.001) and was further augmented to 94% (95% CI, 93-96%) with the combined dashboard and payment incentive program (P=0.001).

This study highlights the impact of both intrinsic (peer norms) and extrinsic (payments) motivation, as they work synergistically to improve VTE compliance rates.

Bottom line: Transparent feedback through real-time dashboards and performance-based payment incentives can be used to bring about significant improvement in patient safety and quality benchmarks.

Citation: Michtalik HJ, Carolan HT, Haut ER, et al. Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis. J Hosp Med. 2015;10(3):172-178.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: Does implementing a patient verification dialog that appears at the beginning of each ordering session, accompanied by a 2.5-second delay, decrease wrong-patient orders?

Background: Computerized provider order entry (CPOE) is known to increase the rate of wrong-patient order entry and, although the rate in the ED has not been well characterized, CPOE wrong-patient order entry has been known to lead to fatalities in the emergency setting.

Study design: A parallel-controlled, experimental, before-after design.

Setting: Five teaching hospital EDs were included in New York City: two adult EDs, two pediatric EDs, and a combined ED, all totaling 250,000 annual visits.

Synopsis: The EDs in this study implemented a patient verification module into their Allscripts system. This verification included three identifiers: full name, birth date, and medical record number. A 2.5-second delay in ability to close the alert was implemented. All patients in the ED rooms were included in the analysis. The primary outcome was intercepted wrong-patient orders, as measured by number of retract and re-order events.

A baseline data set over four months was compared to immediate post-intervention data, as well as data two years post-intervention, with 30% and 25% reductions in the rate of wrong-patient orders, respectively. Of all retractions, 41% were for diagnostic procedures, 21% for medications, and 38% were nursing and miscellaneous orders. The majority of orders were placed by resident physicians (51%), followed by attending physicians (34%), physician assistants (12%), and others (3%).

This method of observation is limited to identified and corrected wrong-patient orders.

Bottom line: Implementing a patient verification alert can significantly decrease the number of order retractions and re-orders due to wrong-patient order entry in the ED setting.

Citation: Green RA, Hripcsak G, Salmasian H, et al. Intercepting wrong-patient orders in a computerized provider order entry system [published online ahead of print December 17, 2014]. Ann Emerg Med.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What is the incidence of transfusion-associated circulatory overload (TACO) as it relates to specific characteristics of patients and transfusion situations?

Background: TACO is the second-leading cause of transfusion-related fatalities; however, the epidemiology of TACO is centered mostly on patients in the ICU, and the epidemiology for noncardiac surgical patients is not well characterized. This might result in suboptimal care delivery and unfavorable outcomes in peri-operative patients.

Study design: Retrospective cohort study.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: Using an electronic algorithm, 2,162 and 1,908 patients in 2004 and 2011, respectively, were screened for TACO if they received intra-operative transfusions during noncardiac surgery with general anesthesia. Analyses evaluated associations between patient and transfusion characteristics with TACO rates. Patients with TACO were compared to complication-free transfused counterparts.

The incidence of TACO increased significantly with the volume of blood product transfused, advanced age, and total intra-operative fluid balance. Mixed blood products had highest incidence of TACO, followed by fresh frozen plasma. Vascular, transplant, and thoracic surgeries had the highest, and obstetric and gynecologic surgeries the lowest TACO rates. Patients with TACO, compared with their counterparts, had a longer ICU and hospital length of stay.

The study population is derived from a single tertiary care referral center and confounded by referral bias, and, therefore, not easily generalizable. Also, results cannot be generalized to nongeneral anesthesia patients.

Although associations were noted between certain characteristics and the development of TACO, more robust and definitive evaluations of TACO risk factors are needed, as many rates were not adjusted for confounding factors.

Bottom line: Understanding characteristics of at-risk patients may facilitate improved decision making regarding transfusion strategies for peri-operative noncardiac surgical patients.

Citation: Clifford L, Jia Q, Yadav H, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122(1):21-28.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: What characteristics in patients with acute encephalitis portend a worse prognosis?

Background: Acute encephalitis is a serious neurologic disease with high levels of associated morbidity, mortality, and cost of care. Yet, little is known about the factors that affect the outcome of patients with encephalitis.

Study design: Retrospective chart review of all consecutive patients diagnosed with acute encephalitis.

Setting: Mayo Clinic, Rochester, Minn.

Synopsis: A retrospective chart review revealed 198 patients with encephalitis, grouped into viral, autoimmune, or unknown/other encephalitis categories, with mortality rates of 8%, 12%, and 5%, respectively. Researchers calculated a modified Rankin Scale score (mRS) on factors associated with good (mRS=0-2) or poor (mRS=3-6) outcome after one year. Factors associated with poor outcome included age 65 or older, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia. Unlike some previous studies, MRI findings and seizure activity did not portend a poor outcome. For viral encephalitis, cerebrospinal fluid polymorphonuclear cell count was also strongly associated with poor outcome.

This is one of the first studies to evaluate functional outcome or distant follow-up; however, it has inherent biases related to the retrospective design, and the results are not necessarily generalizable to all hospitals; there might be an underlying referral bias, given the fact that one third of the patients were referred to the center for further evaluation.

This study does suggest aggressive treatment should be pursued, even in patients with severe presentation, given the possibility of favorable recovery.

Bottom line: Advanced age, immunocompromised state, coma, mechanical ventilation, and acute thrombocytopenia portend a worse outcome for patients with acute encephalitis.

Citation: Singh TD, Fugate JE, Rabinstein AA. The spectrum of acute encephalitis: causes, management, and predictors of outcome. Neurology. 2015;84(4):359-366.

Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?

Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.

Study Design: Retrospective cohort study.

Setting: Fifty-three hospitals in Washington.

Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:

1. Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
2. Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
3. Diabetics may be better adapted to hyperglycemia than nondiabetics.

Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.

Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97-103.

Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?

Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.

Study Design: Retrospective cohort study.

Setting: Fifty-three hospitals in Washington.

Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:

1. Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
2. Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
3. Diabetics may be better adapted to hyperglycemia than nondiabetics.

Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.

Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97-103.

Clinical question: How does peri-operative hyperglycemia affect the risk of adverse events in diabetic patients compared to nondiabetic patients?

Background: Peri-operative hyperglycemia is associated with increased rates of infection, myocardial infarction, stroke, and death. Recent studies suggest that nondiabetics are more prone to hyperglycemia-related complications than diabetics. This study sought to analyze the effect and mechanism by which nondiabetics may be at increased risk for such complications.

Study Design: Retrospective cohort study.

Setting: Fifty-three hospitals in Washington.

Synopsis: Among 40,836 patients who underwent surgery, diabetics had a higher rate of peri-operative adverse events overall compared to nondiabetics (12% vs. 9%, P<0.001). Peri-operative hyperglycemia, defined as blood glucose 180 or greater, was also associated with an increased rate of adverse events. Ironically, this association was more significant in nondiabetic patients [OR 1.6; 95% CI, 1.3-2.1] than in diabetic patients (OR, 0.8; 95% CI, 0.6-1.0). Although the exact reason for this is unknown, existing theories include the following:

1. Diabetics are more apt to receive insulin for peri-operative hyperglycemia than nondiabetics (P<0.001);
2. Hyperglycemia in diabetics may be a less reliable marker of surgical stress than in nondiabetics; and
3. Diabetics may be better adapted to hyperglycemia than nondiabetics.

Bottom Line: Peri-operative hyperglycemia leads to an increased risk of adverse events; this relationship is more pronounced in nondiabetic patients than in diabetic patients.

Citation: Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97-103.

Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?

Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.

Study design: Cross-sectional, anonymous survey study.

Setting: Surveys sent to members of the British Medical Association.

Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.

Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.

Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.

Citation: Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015;5(1):e006687.

Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?

Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.

Study design: Cross-sectional, anonymous survey study.

Setting: Surveys sent to members of the British Medical Association.

Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.

Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.

Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.

Citation: Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015;5(1):e006687.

Clinical question: What is the impact of complaints on doctors’ psychological welfare and health?

Background: Studies have shown that malpractice litigation is associated with physician depression and suicide. Though complaints and investigations are part of appropriate physician oversight, unintentional consequences, such as defensive medicine and physician burnout, often occur.

Study design: Cross-sectional, anonymous survey study.

Setting: Surveys sent to members of the British Medical Association.

Synopsis: Only 8.3% of 95,636 invited physicians completed the survey. This study demonstrated that 16.9% of doctors with recent or ongoing complaints reported clinically significant symptoms of moderate to severe depression, compared to 9.5% of doctors with no complaints; 15% of doctors in the recent complaints group reported clinically significant levels of anxiety, compared to 7.3% of doctors with no complaints. Overall, 84.7% of doctors with a recent complaint and 79.9% with a past complaint reported changing the way they practiced medicine as a result of the complaint.

Since this study is a cross-sectional survey, it does not prove causation; it is possible that doctors with depression and anxiety are more likely to have complaints filed against them.

Bottom line: Doctors involved with complaints have a high prevalence of depression, anxiety, and suicidal ideation.

Citation: Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015;5(1):e006687.