All Content

Reports of signs of heart failure in adults with COVID-19 have been rare – just four such cases have been published since the outbreak started in China – and now a team of pediatric cardiologists in New York have reported a case of acute but reversible myocardial injury in an infant with COVID-19.

Madhu S. et al. J Am Coll Cardiol Case Rep. 2020 doi: 10.1016/j.jaccas.2020.09.031

SOURCE: Sharma M et al. JACC Case Rep. 2020. doi: 10.1016/j.jaccas.2020.09.031.

Reports of signs of heart failure in adults with COVID-19 have been rare – just four such cases have been published since the outbreak started in China – and now a team of pediatric cardiologists in New York have reported a case of acute but reversible myocardial injury in an infant with COVID-19.

Madhu S. et al. J Am Coll Cardiol Case Rep. 2020 doi: 10.1016/j.jaccas.2020.09.031

SOURCE: Sharma M et al. JACC Case Rep. 2020. doi: 10.1016/j.jaccas.2020.09.031.

Reports of signs of heart failure in adults with COVID-19 have been rare – just four such cases have been published since the outbreak started in China – and now a team of pediatric cardiologists in New York have reported a case of acute but reversible myocardial injury in an infant with COVID-19.

Madhu S. et al. J Am Coll Cardiol Case Rep. 2020 doi: 10.1016/j.jaccas.2020.09.031

SOURCE: Sharma M et al. JACC Case Rep. 2020. doi: 10.1016/j.jaccas.2020.09.031.

Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.

Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.

“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.

In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.

In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.

The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.

The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.

“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
 

Tune in to risks in older adults

The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.

“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”

The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
 

Focus research on infection prevention, cost burden

“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.

SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.

Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.

Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.

“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.

In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.

In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.

The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.

The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.

“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
 

Tune in to risks in older adults

The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.

“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”

The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
 

Focus research on infection prevention, cost burden

“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.

SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.

Adults older than 65 years with inflammatory bowel diseases (IBD) had significantly higher rates of inpatient mortality, compared with those younger than 65 years, independent of factors including disease severity, based on data from more than 200,000 hospital admissions.

Older adults use a disproportionate share of health care resources, but data on outcomes among hospitalized older adults with gastrointestinal illness are limited, Jeffrey Schwartz, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues wrote in the Journal of Clinical Gastroenterology.

“In particular, there remains a significant concern that elderly patients are more susceptible to the development of opportunistic infections and malignancy in the setting of biological therapy, which has evolved into the standard of care for IBD over the past 10 years,” they wrote.

In their study, the researchers identified 162,800 hospital admissions for Crohn’s disease and 96,450 admissions for ulcerative colitis. Of these, 20% and 30%, respectively, were older than 65 years, which the researchers designated as the geriatric group.

In a multivariate analysis, age older than 65 years was significantly associated with increased mortality in both Crohn’s disease (odds ratio, 3.47; 95% confidence interval, 2.72-4.44; P < .001) and ulcerative colitis (OR, 2.75; 95% CI, 2.16-3.49; P < .001). The association was independent of factors included comorbidities, admission type, hospital type, inpatient surgery, and IBD subtype.

The most frequent cause of death in both groups across all ages and disease subtypes was infections (approximately 80% for all groups). The total hospital length of stay was significantly longer for geriatric patients, compared with younger patients with Crohn’s disease, in multivariate analysis (average increase, 0.19 days; P = .009). The total charges also were significantly higher among geriatric Crohn’s disease patients, compared with younger patients (average increase, $2,467; P = .012). No significant differences in hospital stay or total charges appeared between geriatric and younger patients with ulcerative colitis.

The study findings were limited by several factors such as the inclusion of older patients with IBD who were hospitalized for other reasons and by the potential for increased mortality because of comorbidities among elderly patients, the researchers noted. However, the findings support the limited data from similar previous studies and showed greater inpatient mortality for older adults with IBD, compared with hospital inpatients overall.

“Given the high prevalence of IBD patients that require inpatient admission, as well as the rapidly aging nature of the U.S. population, further studies are needed targeting geriatric patients with UC [ulcerative colitis] and CD [Crohn’s disease] to improve their overall management and quality of care to determine if this mortality risk can be reduced,” they concluded.
 

Tune in to risks in older adults

The study is important because the percentage of the population older than 65 years has been increasing; “at the same time, we are seeing more elderly patients being newly diagnosed with Crohn’s disease and ulcerative colitis,” said Russell D. Cohen, MD, of the University of Chicago, in an interview. “These patients are more vulnerable to complications of the diseases, such as infections, as well as complications from the medications used to treat these diseases.” However, older adults are often excluded from clinical trials and even from many observational studies in IBD, he noted.

“We have known from past studies that infections such as sepsis are a leading cause of death in our IBD patients,” said Dr. Cohen. “It is also understandable that those patients who have had complicated courses and those with other comorbidities have a higher mortality rate. However, what was surprising in the current study is that, even when the authors controlled for these factors, the geriatric patients still had two and three-quarters to three and a half times the mortality than those who were younger.”

The take-home message for clinicians is that “the geriatric patient with IBD is at a much higher rate for inpatient mortality, most commonly from infectious complications, than younger patients,” Dr. Cohen emphasized. “Quicker attention to what may seem minor but could become a potentially life-threatening infection is imperative. Caution with the use of multiple immune suppressing medications in older patients is paramount, as is timely surgical intervention in IBD patients in whom medications simply are not working.”
 

Focus research on infection prevention, cost burden

“More research should be directed at finding out whether these deadly infections could be prevented, perhaps by preventative ‘prophylactic’ antibiotics in the elderly patients, especially those on multiple immunosuppressive agents,” said Dr. Cohen. “In addition, research into the undue cost burden that these patients place on our health care system and counter that with better access to the newer, safer biological therapies [most of which Medicare does not cover] rather than corticosteroids.”

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Cohen disclosed relationships with multiple companies including AbbVie, Bristol-Myers Squibb/Celgene, Eli Lilly, Gilead Sciences, Janssen, Pfizer, Takeda, and UCB Pharma.

SOURCE: Schwartz J et al. J Clin Gastroenterol. 2020 Nov 23. doi: 10.1097/MCG.0000000000001458.

Obesity and hypoxia at the time of hospital admission predicted more severe disease in children diagnosed with COVID-19, based on data from 281 patients at 8 locations.

Manifestations of COVID-19 in children include respiratory disease similar to that seen in adults, but the full spectrum of disease in children has been studied mainly in single settings or with a focus on one clinical manifestation, wrote Danielle M. Fernandes, MD, of Albert Einstein College of Medicine, New York, and colleagues.

In a study published in the Journal of Pediatrics, the researchers identified 281 children hospitalized with COVID-19 and/or multisystem inflammatory syndrome in children (MIS-C) at 8 sites in Connecticut, New Jersey, and New York. A total of 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations of illness including 32 patients with gastrointestinal problems, 21 infants with fever, 6 cases of neurologic disease, 6 cases of diabetic ketoacidosis, and 4 patients with other indications. The median age of the patients was 10 years, 60% were male, 51% were Hispanic, and 23% were non-Hispanic Black. The most common comorbidities were obesity (34%) and asthma (14%).
 

Independent predictors of disease severity in children found

After controlling for multiple variables, obesity and hypoxia at hospital admission were significant independent predictors of severe respiratory disease, with odds ratios of 3.39 and 4.01, respectively. In addition, lower absolute lymphocyte count (OR, 8.33 per unit decrease in 10⁹ cells/L) and higher C-reactive protein (OR, 1.06 per unit increase in mg/dL) were significantly predictive of severe MIS-C (P = .001 and P = .017, respectively).

“The association between weight and severe respiratory COVID-19 is consistent with the adult literature; however, the mechanisms of this association require further study,” Dr. Fernandes and associates noted.

Overall, children with MIS-C were significantly more likely to be non-Hispanic Black, compared with children with respiratory disease, an 18% difference. However, neither race/ethnicity nor socioeconomic status were significant predictors of disease severity, the researchers wrote.

During the study period, 7 patients (2%) died and 114 (41%) were admitted to the ICU.

“We found a wide array of clinical manifestations in children and youth hospitalized with SARS-CoV-2,” Dr. Fernandes and associates wrote. Notably, gastrointestinal symptoms, ocular symptoms, and dermatologic symptoms have rarely been noted in adults with COVID-19, but occurred in more than 30% of the pediatric patients.

“We also found that SARS-CoV-2 can be an incidental finding in a substantial number of hospitalized pediatric patients,” the researchers said.

The findings were limited by several factors including a population of patients only from Connecticut, New Jersey, and New York, and the possibility that decisions on hospital and ICU admission may have varied by location, the researchers said. In addition, approaches may have varied in the absence of data on the optimal treatment of MIS-C.

“This study builds on the growing body of evidence showing that mortality in hospitalized pediatric patients is low, compared with adults,” Dr. Fernandes and associates said. “However, it highlights that the young population is not universally spared from morbidity, and that even previously healthy children and youth can develop severe disease requiring supportive therapy.”
 

Findings confirm other clinical experience

The study was important to show that, “although most children are spared severe illness from COVID-19, some children are hospitalized both with acute COVID-19 respiratory disease, with MIS-C and with a range of other complications,” Adrienne Randolph, MD, of Boston Children’s Hospital and Harvard Medical School, Boston, said in an interview.

Dr. Randolph said she was not surprised by the study findings, “as we are also seeing these types of complications at Boston Children’s Hospital where I work.”

Additional research is needed on the outcomes of these patients, “especially the longer-term sequelae of having COVID-19 or MIS-C early in life,” she emphasized.

The take-home message to clinicians from the findings at this time is to be aware that children and adolescents can become severely ill from COVID-19–related complications, said Dr. Randolph. “Some of the laboratory values on presentation appear to be associated with disease severity.”

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Randolph disclosed funding from the Centers for Disease Control and Prevention to lead the Overcoming COVID-19 Study in U.S. Children and Adults.

SOURCE: Fernandes DM et al. J Pediatr. 2020 Nov 13. doi: 10.1016/j.jpeds.2020.11.016.

Obesity and hypoxia at the time of hospital admission predicted more severe disease in children diagnosed with COVID-19, based on data from 281 patients at 8 locations.

Manifestations of COVID-19 in children include respiratory disease similar to that seen in adults, but the full spectrum of disease in children has been studied mainly in single settings or with a focus on one clinical manifestation, wrote Danielle M. Fernandes, MD, of Albert Einstein College of Medicine, New York, and colleagues.

In a study published in the Journal of Pediatrics, the researchers identified 281 children hospitalized with COVID-19 and/or multisystem inflammatory syndrome in children (MIS-C) at 8 sites in Connecticut, New Jersey, and New York. A total of 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations of illness including 32 patients with gastrointestinal problems, 21 infants with fever, 6 cases of neurologic disease, 6 cases of diabetic ketoacidosis, and 4 patients with other indications. The median age of the patients was 10 years, 60% were male, 51% were Hispanic, and 23% were non-Hispanic Black. The most common comorbidities were obesity (34%) and asthma (14%).
 

Independent predictors of disease severity in children found

After controlling for multiple variables, obesity and hypoxia at hospital admission were significant independent predictors of severe respiratory disease, with odds ratios of 3.39 and 4.01, respectively. In addition, lower absolute lymphocyte count (OR, 8.33 per unit decrease in 10⁹ cells/L) and higher C-reactive protein (OR, 1.06 per unit increase in mg/dL) were significantly predictive of severe MIS-C (P = .001 and P = .017, respectively).

“The association between weight and severe respiratory COVID-19 is consistent with the adult literature; however, the mechanisms of this association require further study,” Dr. Fernandes and associates noted.

Overall, children with MIS-C were significantly more likely to be non-Hispanic Black, compared with children with respiratory disease, an 18% difference. However, neither race/ethnicity nor socioeconomic status were significant predictors of disease severity, the researchers wrote.

During the study period, 7 patients (2%) died and 114 (41%) were admitted to the ICU.

“We found a wide array of clinical manifestations in children and youth hospitalized with SARS-CoV-2,” Dr. Fernandes and associates wrote. Notably, gastrointestinal symptoms, ocular symptoms, and dermatologic symptoms have rarely been noted in adults with COVID-19, but occurred in more than 30% of the pediatric patients.

“We also found that SARS-CoV-2 can be an incidental finding in a substantial number of hospitalized pediatric patients,” the researchers said.

The findings were limited by several factors including a population of patients only from Connecticut, New Jersey, and New York, and the possibility that decisions on hospital and ICU admission may have varied by location, the researchers said. In addition, approaches may have varied in the absence of data on the optimal treatment of MIS-C.

“This study builds on the growing body of evidence showing that mortality in hospitalized pediatric patients is low, compared with adults,” Dr. Fernandes and associates said. “However, it highlights that the young population is not universally spared from morbidity, and that even previously healthy children and youth can develop severe disease requiring supportive therapy.”
 

Findings confirm other clinical experience

The study was important to show that, “although most children are spared severe illness from COVID-19, some children are hospitalized both with acute COVID-19 respiratory disease, with MIS-C and with a range of other complications,” Adrienne Randolph, MD, of Boston Children’s Hospital and Harvard Medical School, Boston, said in an interview.

Dr. Randolph said she was not surprised by the study findings, “as we are also seeing these types of complications at Boston Children’s Hospital where I work.”

Additional research is needed on the outcomes of these patients, “especially the longer-term sequelae of having COVID-19 or MIS-C early in life,” she emphasized.

The take-home message to clinicians from the findings at this time is to be aware that children and adolescents can become severely ill from COVID-19–related complications, said Dr. Randolph. “Some of the laboratory values on presentation appear to be associated with disease severity.”

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Randolph disclosed funding from the Centers for Disease Control and Prevention to lead the Overcoming COVID-19 Study in U.S. Children and Adults.

SOURCE: Fernandes DM et al. J Pediatr. 2020 Nov 13. doi: 10.1016/j.jpeds.2020.11.016.

Obesity and hypoxia at the time of hospital admission predicted more severe disease in children diagnosed with COVID-19, based on data from 281 patients at 8 locations.

Manifestations of COVID-19 in children include respiratory disease similar to that seen in adults, but the full spectrum of disease in children has been studied mainly in single settings or with a focus on one clinical manifestation, wrote Danielle M. Fernandes, MD, of Albert Einstein College of Medicine, New York, and colleagues.

In a study published in the Journal of Pediatrics, the researchers identified 281 children hospitalized with COVID-19 and/or multisystem inflammatory syndrome in children (MIS-C) at 8 sites in Connecticut, New Jersey, and New York. A total of 143 (51%) had respiratory disease, 69 (25%) had MIS-C, and 69 (25%) had other manifestations of illness including 32 patients with gastrointestinal problems, 21 infants with fever, 6 cases of neurologic disease, 6 cases of diabetic ketoacidosis, and 4 patients with other indications. The median age of the patients was 10 years, 60% were male, 51% were Hispanic, and 23% were non-Hispanic Black. The most common comorbidities were obesity (34%) and asthma (14%).
 

Independent predictors of disease severity in children found

After controlling for multiple variables, obesity and hypoxia at hospital admission were significant independent predictors of severe respiratory disease, with odds ratios of 3.39 and 4.01, respectively. In addition, lower absolute lymphocyte count (OR, 8.33 per unit decrease in 10⁹ cells/L) and higher C-reactive protein (OR, 1.06 per unit increase in mg/dL) were significantly predictive of severe MIS-C (P = .001 and P = .017, respectively).

“The association between weight and severe respiratory COVID-19 is consistent with the adult literature; however, the mechanisms of this association require further study,” Dr. Fernandes and associates noted.

Overall, children with MIS-C were significantly more likely to be non-Hispanic Black, compared with children with respiratory disease, an 18% difference. However, neither race/ethnicity nor socioeconomic status were significant predictors of disease severity, the researchers wrote.

During the study period, 7 patients (2%) died and 114 (41%) were admitted to the ICU.

“We found a wide array of clinical manifestations in children and youth hospitalized with SARS-CoV-2,” Dr. Fernandes and associates wrote. Notably, gastrointestinal symptoms, ocular symptoms, and dermatologic symptoms have rarely been noted in adults with COVID-19, but occurred in more than 30% of the pediatric patients.

“We also found that SARS-CoV-2 can be an incidental finding in a substantial number of hospitalized pediatric patients,” the researchers said.

The findings were limited by several factors including a population of patients only from Connecticut, New Jersey, and New York, and the possibility that decisions on hospital and ICU admission may have varied by location, the researchers said. In addition, approaches may have varied in the absence of data on the optimal treatment of MIS-C.

“This study builds on the growing body of evidence showing that mortality in hospitalized pediatric patients is low, compared with adults,” Dr. Fernandes and associates said. “However, it highlights that the young population is not universally spared from morbidity, and that even previously healthy children and youth can develop severe disease requiring supportive therapy.”
 

Findings confirm other clinical experience

The study was important to show that, “although most children are spared severe illness from COVID-19, some children are hospitalized both with acute COVID-19 respiratory disease, with MIS-C and with a range of other complications,” Adrienne Randolph, MD, of Boston Children’s Hospital and Harvard Medical School, Boston, said in an interview.

Dr. Randolph said she was not surprised by the study findings, “as we are also seeing these types of complications at Boston Children’s Hospital where I work.”

Additional research is needed on the outcomes of these patients, “especially the longer-term sequelae of having COVID-19 or MIS-C early in life,” she emphasized.

The take-home message to clinicians from the findings at this time is to be aware that children and adolescents can become severely ill from COVID-19–related complications, said Dr. Randolph. “Some of the laboratory values on presentation appear to be associated with disease severity.”

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Randolph disclosed funding from the Centers for Disease Control and Prevention to lead the Overcoming COVID-19 Study in U.S. Children and Adults.

SOURCE: Fernandes DM et al. J Pediatr. 2020 Nov 13. doi: 10.1016/j.jpeds.2020.11.016.

Background: New-onset POAF occurs with 10% of noncardiac surgery and 15%-42% of cardiac surgery. POAF is believed to be self-limiting and most patients revert to sinus rhythm before hospital discharge. Previous studies on this topic are both limited and conflicting, but several suggest there is an association of stroke and mortality with POAF.

New-onset POAF was associated with increased risk of early stroke (OR, 1.62; 95% CI, 1.47-1.80) and early mortality (OR, 1.44; 95% CI, 1.11-1.88). POAF also was associated with risk for long-term stroke (hazard ratio, 1.37; 95% CI, 1.07-1.77) and long-term mortality (HR, 1.37; 95% CI, 1.27-1.49). The risk of long-term stroke from new-onset POAF was highest among patients who received noncardiac surgery.

Despite identifying high-quality studies with thoughtful analysis, some data had the potential for publication bias. The representative sample did not report paroxysmal vs. persistent atrial fibrillation separately. Furthermore, the study had the potential to be confounded by detection bias of preexisting atrial fibrillation.

Bottom line: New-onset POAF is associated with early and long-term risk of stroke and mortality. Subsequent strategies to reduce this risk have yet to be determined.

Citation: Lin MH et al. Perioperative/postoperative atrial fibrillation and risk of subsequent stroke and/or mortality. Stroke. 2019 May;50:1364-71.

Dr. Mayer is a hospitalist and assistant professor of medicine at St. Louis University School of Medicine.

Background: New-onset POAF occurs with 10% of noncardiac surgery and 15%-42% of cardiac surgery. POAF is believed to be self-limiting and most patients revert to sinus rhythm before hospital discharge. Previous studies on this topic are both limited and conflicting, but several suggest there is an association of stroke and mortality with POAF.

New-onset POAF was associated with increased risk of early stroke (OR, 1.62; 95% CI, 1.47-1.80) and early mortality (OR, 1.44; 95% CI, 1.11-1.88). POAF also was associated with risk for long-term stroke (hazard ratio, 1.37; 95% CI, 1.07-1.77) and long-term mortality (HR, 1.37; 95% CI, 1.27-1.49). The risk of long-term stroke from new-onset POAF was highest among patients who received noncardiac surgery.

Despite identifying high-quality studies with thoughtful analysis, some data had the potential for publication bias. The representative sample did not report paroxysmal vs. persistent atrial fibrillation separately. Furthermore, the study had the potential to be confounded by detection bias of preexisting atrial fibrillation.

Bottom line: New-onset POAF is associated with early and long-term risk of stroke and mortality. Subsequent strategies to reduce this risk have yet to be determined.

Citation: Lin MH et al. Perioperative/postoperative atrial fibrillation and risk of subsequent stroke and/or mortality. Stroke. 2019 May;50:1364-71.

Dr. Mayer is a hospitalist and assistant professor of medicine at St. Louis University School of Medicine.

Background: New-onset POAF occurs with 10% of noncardiac surgery and 15%-42% of cardiac surgery. POAF is believed to be self-limiting and most patients revert to sinus rhythm before hospital discharge. Previous studies on this topic are both limited and conflicting, but several suggest there is an association of stroke and mortality with POAF.

New-onset POAF was associated with increased risk of early stroke (OR, 1.62; 95% CI, 1.47-1.80) and early mortality (OR, 1.44; 95% CI, 1.11-1.88). POAF also was associated with risk for long-term stroke (hazard ratio, 1.37; 95% CI, 1.07-1.77) and long-term mortality (HR, 1.37; 95% CI, 1.27-1.49). The risk of long-term stroke from new-onset POAF was highest among patients who received noncardiac surgery.

Despite identifying high-quality studies with thoughtful analysis, some data had the potential for publication bias. The representative sample did not report paroxysmal vs. persistent atrial fibrillation separately. Furthermore, the study had the potential to be confounded by detection bias of preexisting atrial fibrillation.

Bottom line: New-onset POAF is associated with early and long-term risk of stroke and mortality. Subsequent strategies to reduce this risk have yet to be determined.

Citation: Lin MH et al. Perioperative/postoperative atrial fibrillation and risk of subsequent stroke and/or mortality. Stroke. 2019 May;50:1364-71.

Dr. Mayer is a hospitalist and assistant professor of medicine at St. Louis University School of Medicine.

On Dec. 1, the Centers for Medicare & Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule, which finalized proposed changes to Medicare reimbursement rates, including a significant negative budget neutrality adjustment. For hospitalists, the Society of Hospital Medicine estimates that the adjustment will amount to an estimated 8% reduction in Medicare reimbursement rates, which will go into effect on Jan. 1, 2021.

“These cuts are coming at the exact wrong time. During the chaos of 2020, when hospitalists have been essential to responding to the COVID-19 pandemic, they should not be met with a significant pay reduction in 2021,” said Eric E. Howell, MD, MHM, chief executive officer of the Society of Hospital Medicine. “While we at SHM support increasing pay for outpatient primary care, which is driving these cuts, we do not believe now is the right time to make significant adjustments to the Medicare Physician Fee Schedule. We now call on Congress to do the right thing for hospitalists and other frontline providers who have otherwise been lauded as heroes.”

SHM will continue to fight for hospitalists and to advocate to reverse these cuts. To send a message of support to your representatives, visit SHM’s Legislative Action Center and click on “Support the Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020.” To learn more about and become involved with SHM’s advocacy efforts, visit hospitalmedicine.org/advocacy.

On Dec. 1, the Centers for Medicare & Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule, which finalized proposed changes to Medicare reimbursement rates, including a significant negative budget neutrality adjustment. For hospitalists, the Society of Hospital Medicine estimates that the adjustment will amount to an estimated 8% reduction in Medicare reimbursement rates, which will go into effect on Jan. 1, 2021.

“These cuts are coming at the exact wrong time. During the chaos of 2020, when hospitalists have been essential to responding to the COVID-19 pandemic, they should not be met with a significant pay reduction in 2021,” said Eric E. Howell, MD, MHM, chief executive officer of the Society of Hospital Medicine. “While we at SHM support increasing pay for outpatient primary care, which is driving these cuts, we do not believe now is the right time to make significant adjustments to the Medicare Physician Fee Schedule. We now call on Congress to do the right thing for hospitalists and other frontline providers who have otherwise been lauded as heroes.”

SHM will continue to fight for hospitalists and to advocate to reverse these cuts. To send a message of support to your representatives, visit SHM’s Legislative Action Center and click on “Support the Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020.” To learn more about and become involved with SHM’s advocacy efforts, visit hospitalmedicine.org/advocacy.

On Dec. 1, the Centers for Medicare & Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule, which finalized proposed changes to Medicare reimbursement rates, including a significant negative budget neutrality adjustment. For hospitalists, the Society of Hospital Medicine estimates that the adjustment will amount to an estimated 8% reduction in Medicare reimbursement rates, which will go into effect on Jan. 1, 2021.

“These cuts are coming at the exact wrong time. During the chaos of 2020, when hospitalists have been essential to responding to the COVID-19 pandemic, they should not be met with a significant pay reduction in 2021,” said Eric E. Howell, MD, MHM, chief executive officer of the Society of Hospital Medicine. “While we at SHM support increasing pay for outpatient primary care, which is driving these cuts, we do not believe now is the right time to make significant adjustments to the Medicare Physician Fee Schedule. We now call on Congress to do the right thing for hospitalists and other frontline providers who have otherwise been lauded as heroes.”

SHM will continue to fight for hospitalists and to advocate to reverse these cuts. To send a message of support to your representatives, visit SHM’s Legislative Action Center and click on “Support the Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020.” To learn more about and become involved with SHM’s advocacy efforts, visit hospitalmedicine.org/advocacy.

As I write this, we are entering the third surge of the COVID-19 pandemic, with new cases, hospitalizations, and deaths from COVID-19 skyrocketing around the country. Worst of all, this surge has been most severely affecting areas of the nation least prepared to handle it (rural) and populations already marginalized by the health care system (Latinx and Black). Despite the onslaught of COVID-19, “pandemic fatigue” has begun to set in amongst colleagues, friends, and family, leading to challenges in adhering to social distancing and other infection-control measures, both at work and home.

Royal Geographic Society, public domain, via Wikimedia Commons

In the face of the pandemic’s onslaught, hospitalists – who have faced the brunt of caring for patients with COVID-19, despite the absence of reporting about the subspecialty’s role – are faced with mustering the grit to respond with resolve, coordinated action, and empathy. Luckily, hospitalists are equipped with the very characteristics needed to lead teams, groups, and hospitals through the crisis of this pandemic. Ask yourself, why did you become a hospitalist? If you wanted steady predictability and control, there were many office-based specialties you could have chosen. You chose to become a hospitalist because you seek the challenges of clinical variety, problem-solving, systems improvement, and you are a natural team leader, whether you have been designated as such or not. In the words of John Quincy Adams, “if your actions inspire others to dream more, learn more, do more, and become more, you are a leader.”

As a leader, how can you lead your team through the series of trials and tribulations that this year has thrown at you? From COVID-19 to racism directed against Black and Latinx people to the behavioral health crisis, 2020 has likely made you feel as if you’re stuck in a ghoulish carnival fun house without an exit.

Yet this is where some leaders hit their stride, in what Bennis and Thomas describe as the “crucible of leadership.”¹ There are many types of “crucibles of leadership,” according to Bennis and Thomas, and this year has thrown most of these at us: prejudice/bias, physical fatigue and illness, sudden elevation of responsibility to lead new processes, not to mention family stressors. Leaders who succeed in guiding their colleagues through these challenges have manifested critical skills: engaging others in shared meaning, having a distinctive and compelling voice, displaying integrity, and having adaptive capacity.

What exactly is adaptive capacity, the most important of these, in my opinion? Adaptive capacity requires understanding the new context of a crisis and how it has shifted team members’ needs and perceptions. It also requires what Bennis and Thomas call hardiness and what I call grit – the ability to face adversity, get knocked down, get up, and do it again.

There is probably no better example of a crisis leader with extraordinary adaptive capacity than Anglo-Irish explorer Sir Ernest Shackleton. Bitten by the bug of exploration, Shackleton failed at reaching the South Pole (1908-1909) but subsequently attempted to cross the Antarctic, departing South Georgia Island on Dec. 5, 1914. Depressingly for Shackleton, his ship, the Endurance, became stuck in sea ice on Jan. 19, 1915 before even reaching the continent. Drifting with the ice floe, his crew had set up a winter station hoping to be released from the ice later, but the Endurance was crushed by the pressure of sea ice and sank on Nov. 21, 1915. From there, Shackleton hoped to drift north to Paulet Island, 250 miles away, but eventually was forced to take his crew on lifeboats to the nearest land, Elephant Island, 346 miles from where the Endurance sank. He then took five of his men on an open boat, 828-mile journey to South Georgia Island. Encountering hurricane-force winds, the team landed on South Georgia Island 15 days later, only to face a climb of 32 miles over mountainous terrain to reach a whaling station. Shackleton eventually organized his men’s rescue on Elephant Island, reaching them on Aug. 30, 1916, 4½ months after he had set out for South Georgia Island. His entire crew survived, only to have two of them killed later in World War I.

You might consider Shackleton a failure for not even coming close to his original goal, but his success in saving his crew is regarded as the epitome of crisis leadership. As Harvard Business School professor Nancy F. Koehn, PhD, whose case study of Shackleton is one of the most popular at HBS, stated, “He thought he was going to be an entrepreneur of exploration, but he became an entrepreneur of survival.”² Upon realizing the futility of his original mission, he pivoted immediately to the survival of his crew. “A man must shape himself to a new mark directly the old one goes to ground,” wrote Shackleton in his diary.³

Realizing that preserving his crew’s morale was critical, he maintained the crew’s everyday activities, despite the prospect of dying on the ice. He realized that he needed to keep up his own courage and confidence as well as that of his crew. Despite his ability to share the strategic focus of getting to safety with his men, he didn’t lose sight of day-to-day needs, such as keeping the crew entertained. When he encountered crew members who seemed problematic to his mission goals, he assigned them to his own tent.

Despite the extreme cold, his decision-making did not freeze – he acted decisively. He took risks when he thought appropriate, twice needing to abandon his efforts to drag a lifeboat full of supplies with his men toward the sea. “You can’t be afraid to make smart mistakes,” says Dr. Koehn. “That’s something we have no training in.”⁴ Most importantly, Shackleton took ultimate responsibility for his men’s survival, never resting until they had all been rescued. And he modeled a culture of shared responsibility for one another⁵ – he had once offered his only biscuit of the day on a prior expedition to his fellow explorer Frank Wild.

As winter arrives in 2020 and deepens into 2021, we will all be faced with leading our teams across the ice and to the safety of spring, and hopefully a vaccine. Whether we can get there with our entire crew depends on effective crisis leadership. But we can draw on the lessons provided by Shackleton and other crisis leaders in the past to guide us in the present.

Author disclosure: I studied the HBS case study “Leadership in Crisis: Ernest Shackleton and the Epic Voyage of the Endurance” as part of a 12-month certificate course in Safety, Quality, Informatics, and Leadership (SQIL) offered by Harvard Medical School.
 

Dr. Chang is chief of pediatric hospital medicine at Baystate Children’s Hospital in Springfield, Mass., and associate professor of pediatrics at the University of Massachusetts, also in Springfield.

References

1. HBR’s 10 must reads on leadership. Boston: Harvard Business Review Press, 2011.

2. Lagace M. Shackleton: An entrepreneur of survival. Harvard Business School. Working Knowledge website. Published 2003. Accessed 2020 Nov 19.

3. Koehn N. Leadership lessons from the Shackleton Expedition. The New York Times. 2011 Dec 25.

4. Potier B. Shackleton in business school. Harvard Public Affairs and Communications. The Harvard Gazette website. Published 2004. Accessed 2020 Nov 19.

5. Perkins D. 4 Lessons in crisis leadership from Shackleton’s expedition. In Leadership Essentials by HarpersCollins Leadership. Vol 2020. New York: HarpersCollins, 2020.

As I write this, we are entering the third surge of the COVID-19 pandemic, with new cases, hospitalizations, and deaths from COVID-19 skyrocketing around the country. Worst of all, this surge has been most severely affecting areas of the nation least prepared to handle it (rural) and populations already marginalized by the health care system (Latinx and Black). Despite the onslaught of COVID-19, “pandemic fatigue” has begun to set in amongst colleagues, friends, and family, leading to challenges in adhering to social distancing and other infection-control measures, both at work and home.

Royal Geographic Society, public domain, via Wikimedia Commons

In the face of the pandemic’s onslaught, hospitalists – who have faced the brunt of caring for patients with COVID-19, despite the absence of reporting about the subspecialty’s role – are faced with mustering the grit to respond with resolve, coordinated action, and empathy. Luckily, hospitalists are equipped with the very characteristics needed to lead teams, groups, and hospitals through the crisis of this pandemic. Ask yourself, why did you become a hospitalist? If you wanted steady predictability and control, there were many office-based specialties you could have chosen. You chose to become a hospitalist because you seek the challenges of clinical variety, problem-solving, systems improvement, and you are a natural team leader, whether you have been designated as such or not. In the words of John Quincy Adams, “if your actions inspire others to dream more, learn more, do more, and become more, you are a leader.”

As a leader, how can you lead your team through the series of trials and tribulations that this year has thrown at you? From COVID-19 to racism directed against Black and Latinx people to the behavioral health crisis, 2020 has likely made you feel as if you’re stuck in a ghoulish carnival fun house without an exit.

Yet this is where some leaders hit their stride, in what Bennis and Thomas describe as the “crucible of leadership.”¹ There are many types of “crucibles of leadership,” according to Bennis and Thomas, and this year has thrown most of these at us: prejudice/bias, physical fatigue and illness, sudden elevation of responsibility to lead new processes, not to mention family stressors. Leaders who succeed in guiding their colleagues through these challenges have manifested critical skills: engaging others in shared meaning, having a distinctive and compelling voice, displaying integrity, and having adaptive capacity.

What exactly is adaptive capacity, the most important of these, in my opinion? Adaptive capacity requires understanding the new context of a crisis and how it has shifted team members’ needs and perceptions. It also requires what Bennis and Thomas call hardiness and what I call grit – the ability to face adversity, get knocked down, get up, and do it again.

There is probably no better example of a crisis leader with extraordinary adaptive capacity than Anglo-Irish explorer Sir Ernest Shackleton. Bitten by the bug of exploration, Shackleton failed at reaching the South Pole (1908-1909) but subsequently attempted to cross the Antarctic, departing South Georgia Island on Dec. 5, 1914. Depressingly for Shackleton, his ship, the Endurance, became stuck in sea ice on Jan. 19, 1915 before even reaching the continent. Drifting with the ice floe, his crew had set up a winter station hoping to be released from the ice later, but the Endurance was crushed by the pressure of sea ice and sank on Nov. 21, 1915. From there, Shackleton hoped to drift north to Paulet Island, 250 miles away, but eventually was forced to take his crew on lifeboats to the nearest land, Elephant Island, 346 miles from where the Endurance sank. He then took five of his men on an open boat, 828-mile journey to South Georgia Island. Encountering hurricane-force winds, the team landed on South Georgia Island 15 days later, only to face a climb of 32 miles over mountainous terrain to reach a whaling station. Shackleton eventually organized his men’s rescue on Elephant Island, reaching them on Aug. 30, 1916, 4½ months after he had set out for South Georgia Island. His entire crew survived, only to have two of them killed later in World War I.

You might consider Shackleton a failure for not even coming close to his original goal, but his success in saving his crew is regarded as the epitome of crisis leadership. As Harvard Business School professor Nancy F. Koehn, PhD, whose case study of Shackleton is one of the most popular at HBS, stated, “He thought he was going to be an entrepreneur of exploration, but he became an entrepreneur of survival.”² Upon realizing the futility of his original mission, he pivoted immediately to the survival of his crew. “A man must shape himself to a new mark directly the old one goes to ground,” wrote Shackleton in his diary.³

Realizing that preserving his crew’s morale was critical, he maintained the crew’s everyday activities, despite the prospect of dying on the ice. He realized that he needed to keep up his own courage and confidence as well as that of his crew. Despite his ability to share the strategic focus of getting to safety with his men, he didn’t lose sight of day-to-day needs, such as keeping the crew entertained. When he encountered crew members who seemed problematic to his mission goals, he assigned them to his own tent.

Despite the extreme cold, his decision-making did not freeze – he acted decisively. He took risks when he thought appropriate, twice needing to abandon his efforts to drag a lifeboat full of supplies with his men toward the sea. “You can’t be afraid to make smart mistakes,” says Dr. Koehn. “That’s something we have no training in.”⁴ Most importantly, Shackleton took ultimate responsibility for his men’s survival, never resting until they had all been rescued. And he modeled a culture of shared responsibility for one another⁵ – he had once offered his only biscuit of the day on a prior expedition to his fellow explorer Frank Wild.

As winter arrives in 2020 and deepens into 2021, we will all be faced with leading our teams across the ice and to the safety of spring, and hopefully a vaccine. Whether we can get there with our entire crew depends on effective crisis leadership. But we can draw on the lessons provided by Shackleton and other crisis leaders in the past to guide us in the present.

Author disclosure: I studied the HBS case study “Leadership in Crisis: Ernest Shackleton and the Epic Voyage of the Endurance” as part of a 12-month certificate course in Safety, Quality, Informatics, and Leadership (SQIL) offered by Harvard Medical School.
 

Dr. Chang is chief of pediatric hospital medicine at Baystate Children’s Hospital in Springfield, Mass., and associate professor of pediatrics at the University of Massachusetts, also in Springfield.

References

1. HBR’s 10 must reads on leadership. Boston: Harvard Business Review Press, 2011.

2. Lagace M. Shackleton: An entrepreneur of survival. Harvard Business School. Working Knowledge website. Published 2003. Accessed 2020 Nov 19.

3. Koehn N. Leadership lessons from the Shackleton Expedition. The New York Times. 2011 Dec 25.

4. Potier B. Shackleton in business school. Harvard Public Affairs and Communications. The Harvard Gazette website. Published 2004. Accessed 2020 Nov 19.

5. Perkins D. 4 Lessons in crisis leadership from Shackleton’s expedition. In Leadership Essentials by HarpersCollins Leadership. Vol 2020. New York: HarpersCollins, 2020.

As I write this, we are entering the third surge of the COVID-19 pandemic, with new cases, hospitalizations, and deaths from COVID-19 skyrocketing around the country. Worst of all, this surge has been most severely affecting areas of the nation least prepared to handle it (rural) and populations already marginalized by the health care system (Latinx and Black). Despite the onslaught of COVID-19, “pandemic fatigue” has begun to set in amongst colleagues, friends, and family, leading to challenges in adhering to social distancing and other infection-control measures, both at work and home.

Royal Geographic Society, public domain, via Wikimedia Commons

In the face of the pandemic’s onslaught, hospitalists – who have faced the brunt of caring for patients with COVID-19, despite the absence of reporting about the subspecialty’s role – are faced with mustering the grit to respond with resolve, coordinated action, and empathy. Luckily, hospitalists are equipped with the very characteristics needed to lead teams, groups, and hospitals through the crisis of this pandemic. Ask yourself, why did you become a hospitalist? If you wanted steady predictability and control, there were many office-based specialties you could have chosen. You chose to become a hospitalist because you seek the challenges of clinical variety, problem-solving, systems improvement, and you are a natural team leader, whether you have been designated as such or not. In the words of John Quincy Adams, “if your actions inspire others to dream more, learn more, do more, and become more, you are a leader.”

As a leader, how can you lead your team through the series of trials and tribulations that this year has thrown at you? From COVID-19 to racism directed against Black and Latinx people to the behavioral health crisis, 2020 has likely made you feel as if you’re stuck in a ghoulish carnival fun house without an exit.

Yet this is where some leaders hit their stride, in what Bennis and Thomas describe as the “crucible of leadership.”¹ There are many types of “crucibles of leadership,” according to Bennis and Thomas, and this year has thrown most of these at us: prejudice/bias, physical fatigue and illness, sudden elevation of responsibility to lead new processes, not to mention family stressors. Leaders who succeed in guiding their colleagues through these challenges have manifested critical skills: engaging others in shared meaning, having a distinctive and compelling voice, displaying integrity, and having adaptive capacity.

What exactly is adaptive capacity, the most important of these, in my opinion? Adaptive capacity requires understanding the new context of a crisis and how it has shifted team members’ needs and perceptions. It also requires what Bennis and Thomas call hardiness and what I call grit – the ability to face adversity, get knocked down, get up, and do it again.

There is probably no better example of a crisis leader with extraordinary adaptive capacity than Anglo-Irish explorer Sir Ernest Shackleton. Bitten by the bug of exploration, Shackleton failed at reaching the South Pole (1908-1909) but subsequently attempted to cross the Antarctic, departing South Georgia Island on Dec. 5, 1914. Depressingly for Shackleton, his ship, the Endurance, became stuck in sea ice on Jan. 19, 1915 before even reaching the continent. Drifting with the ice floe, his crew had set up a winter station hoping to be released from the ice later, but the Endurance was crushed by the pressure of sea ice and sank on Nov. 21, 1915. From there, Shackleton hoped to drift north to Paulet Island, 250 miles away, but eventually was forced to take his crew on lifeboats to the nearest land, Elephant Island, 346 miles from where the Endurance sank. He then took five of his men on an open boat, 828-mile journey to South Georgia Island. Encountering hurricane-force winds, the team landed on South Georgia Island 15 days later, only to face a climb of 32 miles over mountainous terrain to reach a whaling station. Shackleton eventually organized his men’s rescue on Elephant Island, reaching them on Aug. 30, 1916, 4½ months after he had set out for South Georgia Island. His entire crew survived, only to have two of them killed later in World War I.

You might consider Shackleton a failure for not even coming close to his original goal, but his success in saving his crew is regarded as the epitome of crisis leadership. As Harvard Business School professor Nancy F. Koehn, PhD, whose case study of Shackleton is one of the most popular at HBS, stated, “He thought he was going to be an entrepreneur of exploration, but he became an entrepreneur of survival.”² Upon realizing the futility of his original mission, he pivoted immediately to the survival of his crew. “A man must shape himself to a new mark directly the old one goes to ground,” wrote Shackleton in his diary.³

Realizing that preserving his crew’s morale was critical, he maintained the crew’s everyday activities, despite the prospect of dying on the ice. He realized that he needed to keep up his own courage and confidence as well as that of his crew. Despite his ability to share the strategic focus of getting to safety with his men, he didn’t lose sight of day-to-day needs, such as keeping the crew entertained. When he encountered crew members who seemed problematic to his mission goals, he assigned them to his own tent.

Despite the extreme cold, his decision-making did not freeze – he acted decisively. He took risks when he thought appropriate, twice needing to abandon his efforts to drag a lifeboat full of supplies with his men toward the sea. “You can’t be afraid to make smart mistakes,” says Dr. Koehn. “That’s something we have no training in.”⁴ Most importantly, Shackleton took ultimate responsibility for his men’s survival, never resting until they had all been rescued. And he modeled a culture of shared responsibility for one another⁵ – he had once offered his only biscuit of the day on a prior expedition to his fellow explorer Frank Wild.

As winter arrives in 2020 and deepens into 2021, we will all be faced with leading our teams across the ice and to the safety of spring, and hopefully a vaccine. Whether we can get there with our entire crew depends on effective crisis leadership. But we can draw on the lessons provided by Shackleton and other crisis leaders in the past to guide us in the present.

Author disclosure: I studied the HBS case study “Leadership in Crisis: Ernest Shackleton and the Epic Voyage of the Endurance” as part of a 12-month certificate course in Safety, Quality, Informatics, and Leadership (SQIL) offered by Harvard Medical School.
 

Dr. Chang is chief of pediatric hospital medicine at Baystate Children’s Hospital in Springfield, Mass., and associate professor of pediatrics at the University of Massachusetts, also in Springfield.

References

1. HBR’s 10 must reads on leadership. Boston: Harvard Business Review Press, 2011.

2. Lagace M. Shackleton: An entrepreneur of survival. Harvard Business School. Working Knowledge website. Published 2003. Accessed 2020 Nov 19.

3. Koehn N. Leadership lessons from the Shackleton Expedition. The New York Times. 2011 Dec 25.

4. Potier B. Shackleton in business school. Harvard Public Affairs and Communications. The Harvard Gazette website. Published 2004. Accessed 2020 Nov 19.

5. Perkins D. 4 Lessons in crisis leadership from Shackleton’s expedition. In Leadership Essentials by HarpersCollins Leadership. Vol 2020. New York: HarpersCollins, 2020.

Additional blood cultures are not needed after two negative follow-up blood culture results in well-appearing patients with Staphylococcus aureus bacteremia, reported Caitlin Cardenas-Comfort, MD, of the section of pediatric infectious diseases at Baylor College of Medicine, Houston, and colleagues.

CDC/Janice Haney Carr

In a retrospective cohort study of 122 pediatric patients with documented Staphylococcus aureus bacteremia (SAB) that were hospitalized at one of three hospitals in the Texas Children’s Hospital network in Houston, Dr. Cardenas-Comfort and colleagues sought to determine whether specific recommendations can be made on the number of follow-up blood cultures (FUBC) needed to document clearance of SAB. Patients included in the study were under 18 years of age and had confirmed diagnosis of SAB between Jan. 1, and Dec. 31, 2018.
 

Most cases of bacteremia resolve in under 48 hours

In the majority of cases, patients had bacteremia for less than 48 hours and few to no complications. Only 16% of patients experienced bacteremia lasting 3 or more days, and they had either central line-associated bloodstream infection, endocarditis, or osteomyelitis. In such cases, “patients with endovascular and closed-space infections are at an increased risk of persistent bacteremia,” warranting more conservative monitoring and follow-up, cautioned the researchers.

Although Dr. Cardenas-Comfort and colleagues did note an association between the duration of bacteremia and a diagnosis of infectious disease, increased risk for persistent SAB did not appear to be tied to an underlying medical condition, including immunosuppression.

Fewer than 5% of patients with SAB had intermittent positive cultures and fewer than 1% had repeat positive cultures following two negative FUBC results. For those patients with intermittent positive cultures, the risk of being diagnosed with endocarditis or osteomyelitis is more than double. The authors suggested that “source control could be a critical variable” increasing the risk for intermittent positive cultures, noting that surgical debridement occurred more than 24 hours following initial blood draw for every patient in the osteomyelitis group. In contrast, of those who had consistently negative FUBC results, only 2 of 33 (6%) had debridement in the same period, and only 6 of 33 (18%) required more than one debridement.
 

Children are less likely to have intermittent positive cultures

Dr. Cardenas-Comfort and colleagues also observed that intermittent positive cultures may appear less frequently in children than adults, consistent with a recent study of adults in which intermittent cultures were found in 13% of 1.071 SAB cases. In just 4% of the cases in that study, more than 2 days of negative blood cultures preceded a repeat positive culture.

The researchers noted several study limitations in their own research. Because more than half (61%) of patients had two or less FUBCs collected, and 21% one or less, they acknowledged that their conclusions are based on the presumption that the 61% of patients would not have any further positive cultures if they had been drawn. Relying on provider documentation also suggested that cases of bacteremia without an identified source also likely were overrepresented. The retrospective nature of the study only allowed for limited collection of standardized follow-up metrics with the limited patient sample available. Patient characteristics also may have affected the quality of study results because a large number of patients had underlying medical conditions or were premature infants.
 

Look for ongoing hemodynamic instability before third FUBC

Dr. Cardenas-Comfort and colleagues only recommend a third FUBC in cases where patients demonstrate ongoing hemodynamic instability. Applying this to their study population, in retrospect, the authors noted that unnecessary FUBCs could have been prevented in 26% of patients included in the study. They further recommend a thorough clinical evaluation for any patients with SAB lasting 3 or more days with an unidentified infection source. Further research could be beneficial in evaluating cost savings that come from eliminating unnecessary cultures. Additionally, performing a powered analysis would help to determine the probability of an increase in complications based on implementation of these recommendations.

In a separate interview, Tina Q. Tan, MD, infectious disease specialist at Ann & Robert H. Lurie Children’s Hospital of Chicago noted: “This study provides some importance evidence-based guidance on deciding how many blood cultures are needed to demonstrate clearance of S. aureus bacteremia, even in children who have intermittent positive cultures after having negative FUBCs. The recommendation that additional blood cultures to document sterility are not needed after 2 FUBC results are negative in well-appearing children is one that has the potential to decrease cost and unnecessary discomfort in patients. The recommendation currently is for well-appearing children; children who are ill appearing may require further blood cultures to document sterility. Even though this is a single-center study with a relatively small number of patients (n = 122), the information provided is a very useful guide to all clinicians who deal with this issue. Further studies are needed to determine the impact on cost reduction by the elimination of unnecessary blood cultures and whether the rate of complications would increase as a result of not obtaining further cultures in well-appearing children who have two negative follow up blood cultures.”

Dr. Cardenas-Comfort and colleagues as well as Dr. Tan had no conflicts of interest and no relevant financial disclosures. There was no external funding for the study.

SOURCE: Cardenas-Comfort C et al. Pediatrics. 2020. doi: 10.1542/peds.2020-1821.

Additional blood cultures are not needed after two negative follow-up blood culture results in well-appearing patients with Staphylococcus aureus bacteremia, reported Caitlin Cardenas-Comfort, MD, of the section of pediatric infectious diseases at Baylor College of Medicine, Houston, and colleagues.

CDC/Janice Haney Carr

In a retrospective cohort study of 122 pediatric patients with documented Staphylococcus aureus bacteremia (SAB) that were hospitalized at one of three hospitals in the Texas Children’s Hospital network in Houston, Dr. Cardenas-Comfort and colleagues sought to determine whether specific recommendations can be made on the number of follow-up blood cultures (FUBC) needed to document clearance of SAB. Patients included in the study were under 18 years of age and had confirmed diagnosis of SAB between Jan. 1, and Dec. 31, 2018.
 

Most cases of bacteremia resolve in under 48 hours

In the majority of cases, patients had bacteremia for less than 48 hours and few to no complications. Only 16% of patients experienced bacteremia lasting 3 or more days, and they had either central line-associated bloodstream infection, endocarditis, or osteomyelitis. In such cases, “patients with endovascular and closed-space infections are at an increased risk of persistent bacteremia,” warranting more conservative monitoring and follow-up, cautioned the researchers.

Although Dr. Cardenas-Comfort and colleagues did note an association between the duration of bacteremia and a diagnosis of infectious disease, increased risk for persistent SAB did not appear to be tied to an underlying medical condition, including immunosuppression.

Fewer than 5% of patients with SAB had intermittent positive cultures and fewer than 1% had repeat positive cultures following two negative FUBC results. For those patients with intermittent positive cultures, the risk of being diagnosed with endocarditis or osteomyelitis is more than double. The authors suggested that “source control could be a critical variable” increasing the risk for intermittent positive cultures, noting that surgical debridement occurred more than 24 hours following initial blood draw for every patient in the osteomyelitis group. In contrast, of those who had consistently negative FUBC results, only 2 of 33 (6%) had debridement in the same period, and only 6 of 33 (18%) required more than one debridement.
 

Children are less likely to have intermittent positive cultures

Dr. Cardenas-Comfort and colleagues also observed that intermittent positive cultures may appear less frequently in children than adults, consistent with a recent study of adults in which intermittent cultures were found in 13% of 1.071 SAB cases. In just 4% of the cases in that study, more than 2 days of negative blood cultures preceded a repeat positive culture.

The researchers noted several study limitations in their own research. Because more than half (61%) of patients had two or less FUBCs collected, and 21% one or less, they acknowledged that their conclusions are based on the presumption that the 61% of patients would not have any further positive cultures if they had been drawn. Relying on provider documentation also suggested that cases of bacteremia without an identified source also likely were overrepresented. The retrospective nature of the study only allowed for limited collection of standardized follow-up metrics with the limited patient sample available. Patient characteristics also may have affected the quality of study results because a large number of patients had underlying medical conditions or were premature infants.
 

Look for ongoing hemodynamic instability before third FUBC

Dr. Cardenas-Comfort and colleagues only recommend a third FUBC in cases where patients demonstrate ongoing hemodynamic instability. Applying this to their study population, in retrospect, the authors noted that unnecessary FUBCs could have been prevented in 26% of patients included in the study. They further recommend a thorough clinical evaluation for any patients with SAB lasting 3 or more days with an unidentified infection source. Further research could be beneficial in evaluating cost savings that come from eliminating unnecessary cultures. Additionally, performing a powered analysis would help to determine the probability of an increase in complications based on implementation of these recommendations.

In a separate interview, Tina Q. Tan, MD, infectious disease specialist at Ann & Robert H. Lurie Children’s Hospital of Chicago noted: “This study provides some importance evidence-based guidance on deciding how many blood cultures are needed to demonstrate clearance of S. aureus bacteremia, even in children who have intermittent positive cultures after having negative FUBCs. The recommendation that additional blood cultures to document sterility are not needed after 2 FUBC results are negative in well-appearing children is one that has the potential to decrease cost and unnecessary discomfort in patients. The recommendation currently is for well-appearing children; children who are ill appearing may require further blood cultures to document sterility. Even though this is a single-center study with a relatively small number of patients (n = 122), the information provided is a very useful guide to all clinicians who deal with this issue. Further studies are needed to determine the impact on cost reduction by the elimination of unnecessary blood cultures and whether the rate of complications would increase as a result of not obtaining further cultures in well-appearing children who have two negative follow up blood cultures.”

Dr. Cardenas-Comfort and colleagues as well as Dr. Tan had no conflicts of interest and no relevant financial disclosures. There was no external funding for the study.

SOURCE: Cardenas-Comfort C et al. Pediatrics. 2020. doi: 10.1542/peds.2020-1821.

Additional blood cultures are not needed after two negative follow-up blood culture results in well-appearing patients with Staphylococcus aureus bacteremia, reported Caitlin Cardenas-Comfort, MD, of the section of pediatric infectious diseases at Baylor College of Medicine, Houston, and colleagues.

CDC/Janice Haney Carr

In a retrospective cohort study of 122 pediatric patients with documented Staphylococcus aureus bacteremia (SAB) that were hospitalized at one of three hospitals in the Texas Children’s Hospital network in Houston, Dr. Cardenas-Comfort and colleagues sought to determine whether specific recommendations can be made on the number of follow-up blood cultures (FUBC) needed to document clearance of SAB. Patients included in the study were under 18 years of age and had confirmed diagnosis of SAB between Jan. 1, and Dec. 31, 2018.
 

Most cases of bacteremia resolve in under 48 hours

In the majority of cases, patients had bacteremia for less than 48 hours and few to no complications. Only 16% of patients experienced bacteremia lasting 3 or more days, and they had either central line-associated bloodstream infection, endocarditis, or osteomyelitis. In such cases, “patients with endovascular and closed-space infections are at an increased risk of persistent bacteremia,” warranting more conservative monitoring and follow-up, cautioned the researchers.

Although Dr. Cardenas-Comfort and colleagues did note an association between the duration of bacteremia and a diagnosis of infectious disease, increased risk for persistent SAB did not appear to be tied to an underlying medical condition, including immunosuppression.

Fewer than 5% of patients with SAB had intermittent positive cultures and fewer than 1% had repeat positive cultures following two negative FUBC results. For those patients with intermittent positive cultures, the risk of being diagnosed with endocarditis or osteomyelitis is more than double. The authors suggested that “source control could be a critical variable” increasing the risk for intermittent positive cultures, noting that surgical debridement occurred more than 24 hours following initial blood draw for every patient in the osteomyelitis group. In contrast, of those who had consistently negative FUBC results, only 2 of 33 (6%) had debridement in the same period, and only 6 of 33 (18%) required more than one debridement.
 

Children are less likely to have intermittent positive cultures

Dr. Cardenas-Comfort and colleagues also observed that intermittent positive cultures may appear less frequently in children than adults, consistent with a recent study of adults in which intermittent cultures were found in 13% of 1.071 SAB cases. In just 4% of the cases in that study, more than 2 days of negative blood cultures preceded a repeat positive culture.

The researchers noted several study limitations in their own research. Because more than half (61%) of patients had two or less FUBCs collected, and 21% one or less, they acknowledged that their conclusions are based on the presumption that the 61% of patients would not have any further positive cultures if they had been drawn. Relying on provider documentation also suggested that cases of bacteremia without an identified source also likely were overrepresented. The retrospective nature of the study only allowed for limited collection of standardized follow-up metrics with the limited patient sample available. Patient characteristics also may have affected the quality of study results because a large number of patients had underlying medical conditions or were premature infants.
 

Look for ongoing hemodynamic instability before third FUBC

Dr. Cardenas-Comfort and colleagues only recommend a third FUBC in cases where patients demonstrate ongoing hemodynamic instability. Applying this to their study population, in retrospect, the authors noted that unnecessary FUBCs could have been prevented in 26% of patients included in the study. They further recommend a thorough clinical evaluation for any patients with SAB lasting 3 or more days with an unidentified infection source. Further research could be beneficial in evaluating cost savings that come from eliminating unnecessary cultures. Additionally, performing a powered analysis would help to determine the probability of an increase in complications based on implementation of these recommendations.

In a separate interview, Tina Q. Tan, MD, infectious disease specialist at Ann & Robert H. Lurie Children’s Hospital of Chicago noted: “This study provides some importance evidence-based guidance on deciding how many blood cultures are needed to demonstrate clearance of S. aureus bacteremia, even in children who have intermittent positive cultures after having negative FUBCs. The recommendation that additional blood cultures to document sterility are not needed after 2 FUBC results are negative in well-appearing children is one that has the potential to decrease cost and unnecessary discomfort in patients. The recommendation currently is for well-appearing children; children who are ill appearing may require further blood cultures to document sterility. Even though this is a single-center study with a relatively small number of patients (n = 122), the information provided is a very useful guide to all clinicians who deal with this issue. Further studies are needed to determine the impact on cost reduction by the elimination of unnecessary blood cultures and whether the rate of complications would increase as a result of not obtaining further cultures in well-appearing children who have two negative follow up blood cultures.”

Dr. Cardenas-Comfort and colleagues as well as Dr. Tan had no conflicts of interest and no relevant financial disclosures. There was no external funding for the study.

SOURCE: Cardenas-Comfort C et al. Pediatrics. 2020. doi: 10.1542/peds.2020-1821.

Risk of intubation for COVID-19 in very sick hospitalized patients was increased over fivefold in those with diabetic retinopathy, compared with those without, in a small single-center study from the United Kingdom.

Importantly, the risk of intubation was independent of conventional risk factors for poor COVID-19 outcomes.

“People with preexisting diabetes-related vascular damage, such as retinopathy, might be predisposed to a more severe form of COVID-19 requiring ventilation in the intensive therapy unit,” said lead investigator Janaka Karalliedde, MBBS, PhD.

Dr. Karalliedde and colleagues note that this is “the first description of diabetic retinopathy as a potential risk factor for poor COVID-19 outcomes.”

“For this reason, looking for the presence or history of retinopathy or other vascular complications of diabetes may help health care professionals identify patients at high risk of severe COVID-19,” added Dr. Karalliedde, of Guy’s and St Thomas’ NHS Foundation Trust, London.

The study was published online in Diabetes Research and Clinical Practice.
 

Preexisting diabetic retinopathy and COVID-19 outcomes

The prevalence of diabetic retinopathy is thought to be around 55% in people with type 1 diabetes and 30% in people with type 2 diabetes, on average.

Dr. Karalliedde is part of a research group at King’s College London that has been focused on how vascular disease may predispose to more severe COVID-19.

“COVID-19 affects the blood vessels all over the body,” he said, so they wondered whether having preexisting retinopathy “would predispose to a severe manifestation of COVID-19.”

The observational study included 187 patients with diabetes (179 patients with type 2 diabetes and 8 patients with type 1 diabetes) hospitalized with COVID-19 at Guy’s and St Thomas’ NHS Foundation Trust between March 12 and April 7 (the peak of the first wave of the pandemic in the United Kingdom).  

“It was an ethnically diverse population who were very sick and provides a clinical observation of real life,” Dr. Karalliedde said.

Nearly half of patients were African Caribbean (44%), 39% were White, and 17% were of other ethnicities, including 8% who were Asian. The mean age of the cohort was 68 years (range, 22-97 years), and 60% were men.

Diabetic retinopathy was reported in 67 (36%) patients, of whom 80% had background retinopathy and 20% had more advanced retinopathy.

They then looked at whether the presence of retinopathy was associated with a more severe manifestation of COVID-19 as defined by the need for tracheal intubation.

Of the 187 patients, 26% were intubated and 45% of these patients had diabetic retinopathy.

The analysis showed those with diabetic retinopathy had an over-fivefold increased risk for intubation (odds ratio, 5.81; 95% confidence interval, 1.37-24.66).

Of the entire cohort, 32% of patients died, although no association was observed between retinopathy and mortality.

“A greater number of diabetes patients with COVID-19 ended up on the intensive therapy unit. Upon multivariate analysis, we found retinopathy was independently associated with ending up on the intensive therapy unit,” stressed Dr. Karalliedde.

However, they noted that, “due to the cross-sectional design of our study, we cannot prove causality [between retinopathy and intubation]. Further studies are required to understand the mechanisms that explain the associations between retinopathy and other indices of microangiopathy with severe COVID-19.”

A version of this article originally appeared on Medscape.com.

Risk of intubation for COVID-19 in very sick hospitalized patients was increased over fivefold in those with diabetic retinopathy, compared with those without, in a small single-center study from the United Kingdom.

Importantly, the risk of intubation was independent of conventional risk factors for poor COVID-19 outcomes.

“People with preexisting diabetes-related vascular damage, such as retinopathy, might be predisposed to a more severe form of COVID-19 requiring ventilation in the intensive therapy unit,” said lead investigator Janaka Karalliedde, MBBS, PhD.

Dr. Karalliedde and colleagues note that this is “the first description of diabetic retinopathy as a potential risk factor for poor COVID-19 outcomes.”

“For this reason, looking for the presence or history of retinopathy or other vascular complications of diabetes may help health care professionals identify patients at high risk of severe COVID-19,” added Dr. Karalliedde, of Guy’s and St Thomas’ NHS Foundation Trust, London.

The study was published online in Diabetes Research and Clinical Practice.
 

Preexisting diabetic retinopathy and COVID-19 outcomes

The prevalence of diabetic retinopathy is thought to be around 55% in people with type 1 diabetes and 30% in people with type 2 diabetes, on average.

Dr. Karalliedde is part of a research group at King’s College London that has been focused on how vascular disease may predispose to more severe COVID-19.

“COVID-19 affects the blood vessels all over the body,” he said, so they wondered whether having preexisting retinopathy “would predispose to a severe manifestation of COVID-19.”

The observational study included 187 patients with diabetes (179 patients with type 2 diabetes and 8 patients with type 1 diabetes) hospitalized with COVID-19 at Guy’s and St Thomas’ NHS Foundation Trust between March 12 and April 7 (the peak of the first wave of the pandemic in the United Kingdom).  

“It was an ethnically diverse population who were very sick and provides a clinical observation of real life,” Dr. Karalliedde said.

Nearly half of patients were African Caribbean (44%), 39% were White, and 17% were of other ethnicities, including 8% who were Asian. The mean age of the cohort was 68 years (range, 22-97 years), and 60% were men.

Diabetic retinopathy was reported in 67 (36%) patients, of whom 80% had background retinopathy and 20% had more advanced retinopathy.

They then looked at whether the presence of retinopathy was associated with a more severe manifestation of COVID-19 as defined by the need for tracheal intubation.

Of the 187 patients, 26% were intubated and 45% of these patients had diabetic retinopathy.

The analysis showed those with diabetic retinopathy had an over-fivefold increased risk for intubation (odds ratio, 5.81; 95% confidence interval, 1.37-24.66).

Of the entire cohort, 32% of patients died, although no association was observed between retinopathy and mortality.

“A greater number of diabetes patients with COVID-19 ended up on the intensive therapy unit. Upon multivariate analysis, we found retinopathy was independently associated with ending up on the intensive therapy unit,” stressed Dr. Karalliedde.

However, they noted that, “due to the cross-sectional design of our study, we cannot prove causality [between retinopathy and intubation]. Further studies are required to understand the mechanisms that explain the associations between retinopathy and other indices of microangiopathy with severe COVID-19.”

A version of this article originally appeared on Medscape.com.

Risk of intubation for COVID-19 in very sick hospitalized patients was increased over fivefold in those with diabetic retinopathy, compared with those without, in a small single-center study from the United Kingdom.

Importantly, the risk of intubation was independent of conventional risk factors for poor COVID-19 outcomes.

“People with preexisting diabetes-related vascular damage, such as retinopathy, might be predisposed to a more severe form of COVID-19 requiring ventilation in the intensive therapy unit,” said lead investigator Janaka Karalliedde, MBBS, PhD.

Dr. Karalliedde and colleagues note that this is “the first description of diabetic retinopathy as a potential risk factor for poor COVID-19 outcomes.”

“For this reason, looking for the presence or history of retinopathy or other vascular complications of diabetes may help health care professionals identify patients at high risk of severe COVID-19,” added Dr. Karalliedde, of Guy’s and St Thomas’ NHS Foundation Trust, London.

The study was published online in Diabetes Research and Clinical Practice.
 

Preexisting diabetic retinopathy and COVID-19 outcomes

The prevalence of diabetic retinopathy is thought to be around 55% in people with type 1 diabetes and 30% in people with type 2 diabetes, on average.

Dr. Karalliedde is part of a research group at King’s College London that has been focused on how vascular disease may predispose to more severe COVID-19.

“COVID-19 affects the blood vessels all over the body,” he said, so they wondered whether having preexisting retinopathy “would predispose to a severe manifestation of COVID-19.”

The observational study included 187 patients with diabetes (179 patients with type 2 diabetes and 8 patients with type 1 diabetes) hospitalized with COVID-19 at Guy’s and St Thomas’ NHS Foundation Trust between March 12 and April 7 (the peak of the first wave of the pandemic in the United Kingdom).  

“It was an ethnically diverse population who were very sick and provides a clinical observation of real life,” Dr. Karalliedde said.

Nearly half of patients were African Caribbean (44%), 39% were White, and 17% were of other ethnicities, including 8% who were Asian. The mean age of the cohort was 68 years (range, 22-97 years), and 60% were men.

Diabetic retinopathy was reported in 67 (36%) patients, of whom 80% had background retinopathy and 20% had more advanced retinopathy.

They then looked at whether the presence of retinopathy was associated with a more severe manifestation of COVID-19 as defined by the need for tracheal intubation.

Of the 187 patients, 26% were intubated and 45% of these patients had diabetic retinopathy.

The analysis showed those with diabetic retinopathy had an over-fivefold increased risk for intubation (odds ratio, 5.81; 95% confidence interval, 1.37-24.66).

Of the entire cohort, 32% of patients died, although no association was observed between retinopathy and mortality.

“A greater number of diabetes patients with COVID-19 ended up on the intensive therapy unit. Upon multivariate analysis, we found retinopathy was independently associated with ending up on the intensive therapy unit,” stressed Dr. Karalliedde.

However, they noted that, “due to the cross-sectional design of our study, we cannot prove causality [between retinopathy and intubation]. Further studies are required to understand the mechanisms that explain the associations between retinopathy and other indices of microangiopathy with severe COVID-19.”

A version of this article originally appeared on Medscape.com.

The coronavirus pandemic has impacted all facets of the education and training of this country’s future hospitalists, including their medical school coursework, elective rotations, clerkships, and residency training – although with variations between settings and localities.

The COVID-19 crisis demanded immediate changes in traditional approaches to medical education. Training programs responded quickly to institute those changes. As hospitals geared up for potential surges in COVID cases starting in mid-March, many onsite training activities for medical students were shut down in order to reserve personal protective equipment for essential personnel and not put learners at risk of catching the virus. A variety of events related to their education were canceled. Didactic presentations and meetings were converted to virtual gatherings on internet platforms such as Zoom. Many of these changes were adopted even in settings with few actual COVID cases.

Medical students on clinical rotations were provided with virtual didactics when in-person clinical experiences were put on hold. In some cases, academic years ended early and fourth-year students graduated early so they might potentially join the hospital work force. Residents’ assignments were also changed, perhaps seeing patients on non–COVID-19 units only or taking different shifts, assignments, or rotations. Public health or research projects replaced elective placements. New electives were created, along with journal clubs, online care conferences, and technology-facilitated, self-directed learning.

But every advancing medical student needs to rotate through an experience of taking care of real patients, said Amy Guiot, MD, MEd, a hospitalist and associate director of medical student education in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. “The Liaison Committee of Medical Education, jointly sponsored by the Association of American Medical Colleges and the American Medical Association, will not let you graduate a medical student without actual hands-on encounters with patients,” she explained.

For future doctors, especially those pursuing internal medicine – many of whom will practice as hospitalists – their training can’t duplicate “in the hospital” experiences except in the hospital, said Dr. Guiot, who is involved in pediatric training for medical students from the University of Cincinnati and residents.

For third- and fourth-year medical students, getting that personal contact with patients has been the hardest part, she added. But from March to May 2020, that experience was completely shut down at CCHMC, as at many medical schools, because of precautions aimed at preventing exposure to the novel coronavirus for both students and patients. That meant hospitals had to get creative, reshuffling schedules and the order of learning experiences; converting everything possible to virtual encounters on platforms such as Zoom; and reducing the length of rotations, the total number of in-person encounters, and the number of learners participating in an activity.

“We needed to use shift work for medical students, which hadn’t been done before,” Dr. Guiot said. Having students on different shifts, including nights, created more opportunities to fit clinical experiences into the schedule. The use of standardized patients – actors following a script who are examined by a student as part of learning how to do a physical exam – was also put on hold.

“Now we’re starting to get it back, but maybe not as often,” she said. “The actor wears a mask. The student wears a mask and shield. But it’s been harder for us to find actors – who tend to be older adults who may fear coming to the medical center – to perform their role, teaching medical students the art of examining a patient.”

Back to basics

The COVID-19 pandemic forced medical schools to get back to basics, figuring out the key competencies students needed to learn, said Alison Whelan, MD, AAMC’s chief medical education officer. Both medical schools and residency programs needed to respond quickly and in new ways, including with course content that would teach students about the virus and its management and treatment.

Schools have faced crises before, responding in real time to SARS (severe acute respiratory syndrome), Ebola, HIV, and natural disasters, Dr. Whelan said. “But there was a nimbleness and rapidity of adapting to COVID – with a lot of sharing of curriculums among medical colleges.” Back in late March, AAMC put out guidelines that recommended removing students from direct patient contact – not just for the student’s protection but for the community’s. A subsequent guidance, released Aug. 14, emphasized the need for medical schools to continue medical education – with appropriate attention to safety and local conditions while working closely with clinical partners.

Dr. Guiot, with her colleague Leslie Farrell, MD, and four very creative medical students, developed an online fourth-year elective course for University of Cincinnati medical students, offered asynchronously. It aimed to transmit a comprehensive understanding of COVID-19, its virology, transmission, clinical prevention, diagnosis and treatment, as well as examining national and international responses to the pandemic and their consequences and related issues of race, ethnicity, socioeconomic status, and health disparities. “We used several articles from the Journal of Hospital Medicine for students to read and discuss,” Dr. Guiot said.

Yale School of Medicine/Anthony DeCarlo

Christopher Sankey, MD, SFHM, associate program director of the traditional internal medicine residency program and associate professor of medicine at Yale University, New Haven, Conn., oversees the inpatient educational experience for internal medicine residents at Yale. “As with most programs, there was a lot of trepidation as we made the transition from in-person to virtual education,” he said.

The two principal, non–ward-based educational opportunities for the Yale residents are morning report, which involves a case-based discussion of various medical issues, usually led by a chief resident, and noon conference, which is more didactic and content based. Both made the transition to virtual meetings for residents.

“We wondered, could these still be well-attended, well-liked, and successful learning experiences if offered virtually? What I found when I surveyed our residents was that the virtual conferences were not only well received, but actually preferred,” Dr. Sankey said. “We have a large campus with lots of internal medicine services, so it’s hard to assemble everyone for meetings. There were also situations in which there were so many residents that they couldn’t all fit into the same room.” Zoom, the virtual platform of choice, has actually increased attendance.

Marc Miller, MD, a pediatric hospitalist at the Cleveland Clinic, helped his team develop a virtual curriculum in pediatrics presented to third-year medical students during the month of May, when medical students were being taken off the wards. “Some third-year students still needed to get their pediatric clerkships done. We had to balance clinical exposure with a lot of other things,” he explained.

The curriculum included a focus on interprofessional aspects of interdisciplinary, family-centered bedside rounds; a COVID literature review; and a lot of case-based scenarios. “Most challenging was how to remake family rounds. We tried to incorporate students into table rounds, but that didn’t feel as valuable,” Dr. Miller said. “Because pediatrics is so family centered, talking to patients and families at the bedside is highly valued. So we had virtual sessions talking about how to do that, with videos to illustrate it put out by Cincinnati Children’s Hospital.”

The most interactive sessions got the best feedback, but all the sessions went over very well, Dr. Miller said. “Larger lessons from COVID include things we already knew, but now with extra importance, such as the need to encourage interactivity to get students to buy in and take part in these conversations – whatever the structure.”

Vineet Arora, MD, MHM, an academic hospitalist and chief medical officer for the clinical learning environment at the University of Chicago, said that the changes wrought by COVID have also produced unexpected gains for medical education. “We’ve also had to think differently and more creatively about how to get the same information across in this new environment,” she explained. “In some cases, we saw that it was easier for learners to attend conferences and meetings online, with increased attendance for our events.” That includes participation on quality improvement committees, and attending online medical conferences presented locally and regionally.

“Another question: How do we teach interdisciplinary rounds and how to work with other members of the team without having face-to-face interactions?” Dr. Arora said. “Our old interdisciplinary rounding model had to change. It forced us to rethink how to create that kind of learning. We can’t have as many people in the patient’s room at one time. Can there be a physically distanced ‘touch-base’ with the nurse outside the patient’s room after a doctor has gone in to meet the patient?”

Transformational change

In a recent JAMA Viewpoint column, Catherine R. Lucey, MD, and S. Claiborne Johnston, MD, PhD,¹ called the impact of COVID-19 “transformational,” in line with changes in medical curriculums recommended by the 2010 Global Independent Commission on Education of Health Professionals for the 21st Century,² which asserted that the purpose of professional education is to improve the health of communities.

The authors stated that COVID-19 brought clarity and urgency to this purpose, and will someday be viewed as a catalyst for the needed transformation of medical education as medical schools embarked on curriculum redesign to embrace new competencies for current health challenges.

They suggested that medical students not only continued to learn during the COVID crisis “but in many circumstances, accelerated their attainment of the types of competencies that 21^st century physicians must master.” Emerging competencies identified by Dr. Lucey and Dr. Johnston include:

• Being able to address population and public health issues
• Designing and continuously improving of the health care system
• Incorporating data and technology in service to patient care, research, and education
• Eliminating health care disparities and discrimination in medicine
• Adapting the curriculum to current issues in real-time
• Engaging in crisis communication and active change leadership

How is the curriculum changing? It’s still a work in progress. “After the disruptions of the spring and summer, schools are now trying to figure which of the changes should stay,” said Dr. Whelan. “The virus has also highlighted other crises, with social determinants of health and racial disparities becoming more front and center. In terms of content, medical educators are rethinking a lot of things – in a good way.”

Another important trend cast in sharper relief by the pandemic is a gradual evolution toward competency-based education and how to assess when someone is ready to be a doctor, Dr. Whelan said. “There’s been an accelerated consideration of how to be sure each student is competent to practice medicine.”³

Many practicing physicians and students were redeployed in the crisis, she said. Pediatric physicians were asked to take care of adult patients, and internists were drafted to work in the ICU. Hospitals quickly developed refresher courses and competency-based assessments to facilitate these redeployments. What can be learned from such on-the-fly assessments? What was needed to make a pediatrician, under the supervision of an internist, able to take good care of adult patients?

And does competency-based assessment point toward some kind of time-variable graduate medical education of the future – with graduation when the competencies are achieved, rather than just tethered to time- and case volume–based requirements? It seems Canada is moving in this direction, and COVID might catalyze a similar transformation in the United States.³

Changing the curriculum

Does the content of the curriculum for preparing future hospitalists need to change significantly? “My honest answer is yes and no,” Dr. Sankey said. “One thing we found in our training program is that it’s possible to become consumed by this pandemic. We need to educate residents about it, but future doctors still need to learn a lot of other things. Heart failure has not gone away.

“It’s okay to stick to the general curriculum, but with a wider variety of learning opportunities. Adding content sessions on population health, social determinants of health, race and bias, and equity is a start, but it’s by no means sufficient to give these topics the importance they deserve. We need to interpolate these subjects into sessions we’re already doing,” he said. “It is not enough to do a couple of lectures on diversity. We need to weave these concepts into the education we provide for residents every day.

“I think the pandemic has posed an opportunity to critically consider what’s the ideal teaching and learning environment. How can we make it better? Societal events around race have demonstrated essential areas for curricular development, and the pandemic had us primed and already thinking about how we educate future doctors – both in terms of medium and content,” he said.

Some medical schools started their new academic year in July; others put it off until September. Patient care at CCHMC is nearly back to where it used to be before COVID-19 began, Dr. Guiot said in a September interview, “but in masks and goggles.” As a result, hospitals are having to get creative all over again to accommodate medical students.

“I am amazed at the camaraderie of hospitals and medical schools, trying to support our learners in the midst of the pandemic,” she said. “I learned that we can be more adaptive than I ever imagined. We were all nervous about the risks, but we learned how to support each other and still provide excellent care in the midst of the pandemic. We’re forever changed. We also learned how to present didactics on Zoom, but that was the easy part.”
 

References

1. Lucey CR, Johnston SC. The transformational effects of COVID-19 on medical education. JAMA. 2020;324(11):1033-4.

2. Bhutta ZA et al. Education of health professionals for the 21st century: A global independent Commission. Lancet. 2010 Apr 3;375(9721):1137-8.

3. Goldhamer MEJ et al. Can COVID catalyze an educational transformation? Competency-based advancement in a crisis. N Engl J Med. 2020;383:1003-5.

The coronavirus pandemic has impacted all facets of the education and training of this country’s future hospitalists, including their medical school coursework, elective rotations, clerkships, and residency training – although with variations between settings and localities.

The COVID-19 crisis demanded immediate changes in traditional approaches to medical education. Training programs responded quickly to institute those changes. As hospitals geared up for potential surges in COVID cases starting in mid-March, many onsite training activities for medical students were shut down in order to reserve personal protective equipment for essential personnel and not put learners at risk of catching the virus. A variety of events related to their education were canceled. Didactic presentations and meetings were converted to virtual gatherings on internet platforms such as Zoom. Many of these changes were adopted even in settings with few actual COVID cases.

Medical students on clinical rotations were provided with virtual didactics when in-person clinical experiences were put on hold. In some cases, academic years ended early and fourth-year students graduated early so they might potentially join the hospital work force. Residents’ assignments were also changed, perhaps seeing patients on non–COVID-19 units only or taking different shifts, assignments, or rotations. Public health or research projects replaced elective placements. New electives were created, along with journal clubs, online care conferences, and technology-facilitated, self-directed learning.

But every advancing medical student needs to rotate through an experience of taking care of real patients, said Amy Guiot, MD, MEd, a hospitalist and associate director of medical student education in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. “The Liaison Committee of Medical Education, jointly sponsored by the Association of American Medical Colleges and the American Medical Association, will not let you graduate a medical student without actual hands-on encounters with patients,” she explained.

For future doctors, especially those pursuing internal medicine – many of whom will practice as hospitalists – their training can’t duplicate “in the hospital” experiences except in the hospital, said Dr. Guiot, who is involved in pediatric training for medical students from the University of Cincinnati and residents.

For third- and fourth-year medical students, getting that personal contact with patients has been the hardest part, she added. But from March to May 2020, that experience was completely shut down at CCHMC, as at many medical schools, because of precautions aimed at preventing exposure to the novel coronavirus for both students and patients. That meant hospitals had to get creative, reshuffling schedules and the order of learning experiences; converting everything possible to virtual encounters on platforms such as Zoom; and reducing the length of rotations, the total number of in-person encounters, and the number of learners participating in an activity.

“We needed to use shift work for medical students, which hadn’t been done before,” Dr. Guiot said. Having students on different shifts, including nights, created more opportunities to fit clinical experiences into the schedule. The use of standardized patients – actors following a script who are examined by a student as part of learning how to do a physical exam – was also put on hold.

“Now we’re starting to get it back, but maybe not as often,” she said. “The actor wears a mask. The student wears a mask and shield. But it’s been harder for us to find actors – who tend to be older adults who may fear coming to the medical center – to perform their role, teaching medical students the art of examining a patient.”

Back to basics

The COVID-19 pandemic forced medical schools to get back to basics, figuring out the key competencies students needed to learn, said Alison Whelan, MD, AAMC’s chief medical education officer. Both medical schools and residency programs needed to respond quickly and in new ways, including with course content that would teach students about the virus and its management and treatment.

Schools have faced crises before, responding in real time to SARS (severe acute respiratory syndrome), Ebola, HIV, and natural disasters, Dr. Whelan said. “But there was a nimbleness and rapidity of adapting to COVID – with a lot of sharing of curriculums among medical colleges.” Back in late March, AAMC put out guidelines that recommended removing students from direct patient contact – not just for the student’s protection but for the community’s. A subsequent guidance, released Aug. 14, emphasized the need for medical schools to continue medical education – with appropriate attention to safety and local conditions while working closely with clinical partners.

Dr. Guiot, with her colleague Leslie Farrell, MD, and four very creative medical students, developed an online fourth-year elective course for University of Cincinnati medical students, offered asynchronously. It aimed to transmit a comprehensive understanding of COVID-19, its virology, transmission, clinical prevention, diagnosis and treatment, as well as examining national and international responses to the pandemic and their consequences and related issues of race, ethnicity, socioeconomic status, and health disparities. “We used several articles from the Journal of Hospital Medicine for students to read and discuss,” Dr. Guiot said.

Yale School of Medicine/Anthony DeCarlo

Christopher Sankey, MD, SFHM, associate program director of the traditional internal medicine residency program and associate professor of medicine at Yale University, New Haven, Conn., oversees the inpatient educational experience for internal medicine residents at Yale. “As with most programs, there was a lot of trepidation as we made the transition from in-person to virtual education,” he said.

The two principal, non–ward-based educational opportunities for the Yale residents are morning report, which involves a case-based discussion of various medical issues, usually led by a chief resident, and noon conference, which is more didactic and content based. Both made the transition to virtual meetings for residents.

“We wondered, could these still be well-attended, well-liked, and successful learning experiences if offered virtually? What I found when I surveyed our residents was that the virtual conferences were not only well received, but actually preferred,” Dr. Sankey said. “We have a large campus with lots of internal medicine services, so it’s hard to assemble everyone for meetings. There were also situations in which there were so many residents that they couldn’t all fit into the same room.” Zoom, the virtual platform of choice, has actually increased attendance.

Marc Miller, MD, a pediatric hospitalist at the Cleveland Clinic, helped his team develop a virtual curriculum in pediatrics presented to third-year medical students during the month of May, when medical students were being taken off the wards. “Some third-year students still needed to get their pediatric clerkships done. We had to balance clinical exposure with a lot of other things,” he explained.

The curriculum included a focus on interprofessional aspects of interdisciplinary, family-centered bedside rounds; a COVID literature review; and a lot of case-based scenarios. “Most challenging was how to remake family rounds. We tried to incorporate students into table rounds, but that didn’t feel as valuable,” Dr. Miller said. “Because pediatrics is so family centered, talking to patients and families at the bedside is highly valued. So we had virtual sessions talking about how to do that, with videos to illustrate it put out by Cincinnati Children’s Hospital.”

The most interactive sessions got the best feedback, but all the sessions went over very well, Dr. Miller said. “Larger lessons from COVID include things we already knew, but now with extra importance, such as the need to encourage interactivity to get students to buy in and take part in these conversations – whatever the structure.”

Vineet Arora, MD, MHM, an academic hospitalist and chief medical officer for the clinical learning environment at the University of Chicago, said that the changes wrought by COVID have also produced unexpected gains for medical education. “We’ve also had to think differently and more creatively about how to get the same information across in this new environment,” she explained. “In some cases, we saw that it was easier for learners to attend conferences and meetings online, with increased attendance for our events.” That includes participation on quality improvement committees, and attending online medical conferences presented locally and regionally.

“Another question: How do we teach interdisciplinary rounds and how to work with other members of the team without having face-to-face interactions?” Dr. Arora said. “Our old interdisciplinary rounding model had to change. It forced us to rethink how to create that kind of learning. We can’t have as many people in the patient’s room at one time. Can there be a physically distanced ‘touch-base’ with the nurse outside the patient’s room after a doctor has gone in to meet the patient?”

Transformational change

In a recent JAMA Viewpoint column, Catherine R. Lucey, MD, and S. Claiborne Johnston, MD, PhD,¹ called the impact of COVID-19 “transformational,” in line with changes in medical curriculums recommended by the 2010 Global Independent Commission on Education of Health Professionals for the 21st Century,² which asserted that the purpose of professional education is to improve the health of communities.

The authors stated that COVID-19 brought clarity and urgency to this purpose, and will someday be viewed as a catalyst for the needed transformation of medical education as medical schools embarked on curriculum redesign to embrace new competencies for current health challenges.

They suggested that medical students not only continued to learn during the COVID crisis “but in many circumstances, accelerated their attainment of the types of competencies that 21^st century physicians must master.” Emerging competencies identified by Dr. Lucey and Dr. Johnston include:

• Being able to address population and public health issues
• Designing and continuously improving of the health care system
• Incorporating data and technology in service to patient care, research, and education
• Eliminating health care disparities and discrimination in medicine
• Adapting the curriculum to current issues in real-time
• Engaging in crisis communication and active change leadership

How is the curriculum changing? It’s still a work in progress. “After the disruptions of the spring and summer, schools are now trying to figure which of the changes should stay,” said Dr. Whelan. “The virus has also highlighted other crises, with social determinants of health and racial disparities becoming more front and center. In terms of content, medical educators are rethinking a lot of things – in a good way.”

Another important trend cast in sharper relief by the pandemic is a gradual evolution toward competency-based education and how to assess when someone is ready to be a doctor, Dr. Whelan said. “There’s been an accelerated consideration of how to be sure each student is competent to practice medicine.”³

Many practicing physicians and students were redeployed in the crisis, she said. Pediatric physicians were asked to take care of adult patients, and internists were drafted to work in the ICU. Hospitals quickly developed refresher courses and competency-based assessments to facilitate these redeployments. What can be learned from such on-the-fly assessments? What was needed to make a pediatrician, under the supervision of an internist, able to take good care of adult patients?

And does competency-based assessment point toward some kind of time-variable graduate medical education of the future – with graduation when the competencies are achieved, rather than just tethered to time- and case volume–based requirements? It seems Canada is moving in this direction, and COVID might catalyze a similar transformation in the United States.³

Changing the curriculum

Does the content of the curriculum for preparing future hospitalists need to change significantly? “My honest answer is yes and no,” Dr. Sankey said. “One thing we found in our training program is that it’s possible to become consumed by this pandemic. We need to educate residents about it, but future doctors still need to learn a lot of other things. Heart failure has not gone away.

“It’s okay to stick to the general curriculum, but with a wider variety of learning opportunities. Adding content sessions on population health, social determinants of health, race and bias, and equity is a start, but it’s by no means sufficient to give these topics the importance they deserve. We need to interpolate these subjects into sessions we’re already doing,” he said. “It is not enough to do a couple of lectures on diversity. We need to weave these concepts into the education we provide for residents every day.

“I think the pandemic has posed an opportunity to critically consider what’s the ideal teaching and learning environment. How can we make it better? Societal events around race have demonstrated essential areas for curricular development, and the pandemic had us primed and already thinking about how we educate future doctors – both in terms of medium and content,” he said.

Some medical schools started their new academic year in July; others put it off until September. Patient care at CCHMC is nearly back to where it used to be before COVID-19 began, Dr. Guiot said in a September interview, “but in masks and goggles.” As a result, hospitals are having to get creative all over again to accommodate medical students.

“I am amazed at the camaraderie of hospitals and medical schools, trying to support our learners in the midst of the pandemic,” she said. “I learned that we can be more adaptive than I ever imagined. We were all nervous about the risks, but we learned how to support each other and still provide excellent care in the midst of the pandemic. We’re forever changed. We also learned how to present didactics on Zoom, but that was the easy part.”
 

References

1. Lucey CR, Johnston SC. The transformational effects of COVID-19 on medical education. JAMA. 2020;324(11):1033-4.

2. Bhutta ZA et al. Education of health professionals for the 21st century: A global independent Commission. Lancet. 2010 Apr 3;375(9721):1137-8.

3. Goldhamer MEJ et al. Can COVID catalyze an educational transformation? Competency-based advancement in a crisis. N Engl J Med. 2020;383:1003-5.

The coronavirus pandemic has impacted all facets of the education and training of this country’s future hospitalists, including their medical school coursework, elective rotations, clerkships, and residency training – although with variations between settings and localities.

The COVID-19 crisis demanded immediate changes in traditional approaches to medical education. Training programs responded quickly to institute those changes. As hospitals geared up for potential surges in COVID cases starting in mid-March, many onsite training activities for medical students were shut down in order to reserve personal protective equipment for essential personnel and not put learners at risk of catching the virus. A variety of events related to their education were canceled. Didactic presentations and meetings were converted to virtual gatherings on internet platforms such as Zoom. Many of these changes were adopted even in settings with few actual COVID cases.

Medical students on clinical rotations were provided with virtual didactics when in-person clinical experiences were put on hold. In some cases, academic years ended early and fourth-year students graduated early so they might potentially join the hospital work force. Residents’ assignments were also changed, perhaps seeing patients on non–COVID-19 units only or taking different shifts, assignments, or rotations. Public health or research projects replaced elective placements. New electives were created, along with journal clubs, online care conferences, and technology-facilitated, self-directed learning.

But every advancing medical student needs to rotate through an experience of taking care of real patients, said Amy Guiot, MD, MEd, a hospitalist and associate director of medical student education in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. “The Liaison Committee of Medical Education, jointly sponsored by the Association of American Medical Colleges and the American Medical Association, will not let you graduate a medical student without actual hands-on encounters with patients,” she explained.

For future doctors, especially those pursuing internal medicine – many of whom will practice as hospitalists – their training can’t duplicate “in the hospital” experiences except in the hospital, said Dr. Guiot, who is involved in pediatric training for medical students from the University of Cincinnati and residents.

For third- and fourth-year medical students, getting that personal contact with patients has been the hardest part, she added. But from March to May 2020, that experience was completely shut down at CCHMC, as at many medical schools, because of precautions aimed at preventing exposure to the novel coronavirus for both students and patients. That meant hospitals had to get creative, reshuffling schedules and the order of learning experiences; converting everything possible to virtual encounters on platforms such as Zoom; and reducing the length of rotations, the total number of in-person encounters, and the number of learners participating in an activity.

“We needed to use shift work for medical students, which hadn’t been done before,” Dr. Guiot said. Having students on different shifts, including nights, created more opportunities to fit clinical experiences into the schedule. The use of standardized patients – actors following a script who are examined by a student as part of learning how to do a physical exam – was also put on hold.

“Now we’re starting to get it back, but maybe not as often,” she said. “The actor wears a mask. The student wears a mask and shield. But it’s been harder for us to find actors – who tend to be older adults who may fear coming to the medical center – to perform their role, teaching medical students the art of examining a patient.”

Back to basics

The COVID-19 pandemic forced medical schools to get back to basics, figuring out the key competencies students needed to learn, said Alison Whelan, MD, AAMC’s chief medical education officer. Both medical schools and residency programs needed to respond quickly and in new ways, including with course content that would teach students about the virus and its management and treatment.

Schools have faced crises before, responding in real time to SARS (severe acute respiratory syndrome), Ebola, HIV, and natural disasters, Dr. Whelan said. “But there was a nimbleness and rapidity of adapting to COVID – with a lot of sharing of curriculums among medical colleges.” Back in late March, AAMC put out guidelines that recommended removing students from direct patient contact – not just for the student’s protection but for the community’s. A subsequent guidance, released Aug. 14, emphasized the need for medical schools to continue medical education – with appropriate attention to safety and local conditions while working closely with clinical partners.

Dr. Guiot, with her colleague Leslie Farrell, MD, and four very creative medical students, developed an online fourth-year elective course for University of Cincinnati medical students, offered asynchronously. It aimed to transmit a comprehensive understanding of COVID-19, its virology, transmission, clinical prevention, diagnosis and treatment, as well as examining national and international responses to the pandemic and their consequences and related issues of race, ethnicity, socioeconomic status, and health disparities. “We used several articles from the Journal of Hospital Medicine for students to read and discuss,” Dr. Guiot said.

Yale School of Medicine/Anthony DeCarlo

Christopher Sankey, MD, SFHM, associate program director of the traditional internal medicine residency program and associate professor of medicine at Yale University, New Haven, Conn., oversees the inpatient educational experience for internal medicine residents at Yale. “As with most programs, there was a lot of trepidation as we made the transition from in-person to virtual education,” he said.

The two principal, non–ward-based educational opportunities for the Yale residents are morning report, which involves a case-based discussion of various medical issues, usually led by a chief resident, and noon conference, which is more didactic and content based. Both made the transition to virtual meetings for residents.

“We wondered, could these still be well-attended, well-liked, and successful learning experiences if offered virtually? What I found when I surveyed our residents was that the virtual conferences were not only well received, but actually preferred,” Dr. Sankey said. “We have a large campus with lots of internal medicine services, so it’s hard to assemble everyone for meetings. There were also situations in which there were so many residents that they couldn’t all fit into the same room.” Zoom, the virtual platform of choice, has actually increased attendance.

Marc Miller, MD, a pediatric hospitalist at the Cleveland Clinic, helped his team develop a virtual curriculum in pediatrics presented to third-year medical students during the month of May, when medical students were being taken off the wards. “Some third-year students still needed to get their pediatric clerkships done. We had to balance clinical exposure with a lot of other things,” he explained.

The curriculum included a focus on interprofessional aspects of interdisciplinary, family-centered bedside rounds; a COVID literature review; and a lot of case-based scenarios. “Most challenging was how to remake family rounds. We tried to incorporate students into table rounds, but that didn’t feel as valuable,” Dr. Miller said. “Because pediatrics is so family centered, talking to patients and families at the bedside is highly valued. So we had virtual sessions talking about how to do that, with videos to illustrate it put out by Cincinnati Children’s Hospital.”

The most interactive sessions got the best feedback, but all the sessions went over very well, Dr. Miller said. “Larger lessons from COVID include things we already knew, but now with extra importance, such as the need to encourage interactivity to get students to buy in and take part in these conversations – whatever the structure.”

Vineet Arora, MD, MHM, an academic hospitalist and chief medical officer for the clinical learning environment at the University of Chicago, said that the changes wrought by COVID have also produced unexpected gains for medical education. “We’ve also had to think differently and more creatively about how to get the same information across in this new environment,” she explained. “In some cases, we saw that it was easier for learners to attend conferences and meetings online, with increased attendance for our events.” That includes participation on quality improvement committees, and attending online medical conferences presented locally and regionally.

“Another question: How do we teach interdisciplinary rounds and how to work with other members of the team without having face-to-face interactions?” Dr. Arora said. “Our old interdisciplinary rounding model had to change. It forced us to rethink how to create that kind of learning. We can’t have as many people in the patient’s room at one time. Can there be a physically distanced ‘touch-base’ with the nurse outside the patient’s room after a doctor has gone in to meet the patient?”

Transformational change

In a recent JAMA Viewpoint column, Catherine R. Lucey, MD, and S. Claiborne Johnston, MD, PhD,¹ called the impact of COVID-19 “transformational,” in line with changes in medical curriculums recommended by the 2010 Global Independent Commission on Education of Health Professionals for the 21st Century,² which asserted that the purpose of professional education is to improve the health of communities.

The authors stated that COVID-19 brought clarity and urgency to this purpose, and will someday be viewed as a catalyst for the needed transformation of medical education as medical schools embarked on curriculum redesign to embrace new competencies for current health challenges.

They suggested that medical students not only continued to learn during the COVID crisis “but in many circumstances, accelerated their attainment of the types of competencies that 21^st century physicians must master.” Emerging competencies identified by Dr. Lucey and Dr. Johnston include:

• Being able to address population and public health issues
• Designing and continuously improving of the health care system
• Incorporating data and technology in service to patient care, research, and education
• Eliminating health care disparities and discrimination in medicine
• Adapting the curriculum to current issues in real-time
• Engaging in crisis communication and active change leadership

How is the curriculum changing? It’s still a work in progress. “After the disruptions of the spring and summer, schools are now trying to figure which of the changes should stay,” said Dr. Whelan. “The virus has also highlighted other crises, with social determinants of health and racial disparities becoming more front and center. In terms of content, medical educators are rethinking a lot of things – in a good way.”

Another important trend cast in sharper relief by the pandemic is a gradual evolution toward competency-based education and how to assess when someone is ready to be a doctor, Dr. Whelan said. “There’s been an accelerated consideration of how to be sure each student is competent to practice medicine.”³

Many practicing physicians and students were redeployed in the crisis, she said. Pediatric physicians were asked to take care of adult patients, and internists were drafted to work in the ICU. Hospitals quickly developed refresher courses and competency-based assessments to facilitate these redeployments. What can be learned from such on-the-fly assessments? What was needed to make a pediatrician, under the supervision of an internist, able to take good care of adult patients?

And does competency-based assessment point toward some kind of time-variable graduate medical education of the future – with graduation when the competencies are achieved, rather than just tethered to time- and case volume–based requirements? It seems Canada is moving in this direction, and COVID might catalyze a similar transformation in the United States.³

Changing the curriculum

Does the content of the curriculum for preparing future hospitalists need to change significantly? “My honest answer is yes and no,” Dr. Sankey said. “One thing we found in our training program is that it’s possible to become consumed by this pandemic. We need to educate residents about it, but future doctors still need to learn a lot of other things. Heart failure has not gone away.

“It’s okay to stick to the general curriculum, but with a wider variety of learning opportunities. Adding content sessions on population health, social determinants of health, race and bias, and equity is a start, but it’s by no means sufficient to give these topics the importance they deserve. We need to interpolate these subjects into sessions we’re already doing,” he said. “It is not enough to do a couple of lectures on diversity. We need to weave these concepts into the education we provide for residents every day.

“I think the pandemic has posed an opportunity to critically consider what’s the ideal teaching and learning environment. How can we make it better? Societal events around race have demonstrated essential areas for curricular development, and the pandemic had us primed and already thinking about how we educate future doctors – both in terms of medium and content,” he said.

Some medical schools started their new academic year in July; others put it off until September. Patient care at CCHMC is nearly back to where it used to be before COVID-19 began, Dr. Guiot said in a September interview, “but in masks and goggles.” As a result, hospitals are having to get creative all over again to accommodate medical students.

“I am amazed at the camaraderie of hospitals and medical schools, trying to support our learners in the midst of the pandemic,” she said. “I learned that we can be more adaptive than I ever imagined. We were all nervous about the risks, but we learned how to support each other and still provide excellent care in the midst of the pandemic. We’re forever changed. We also learned how to present didactics on Zoom, but that was the easy part.”
 

References

1. Lucey CR, Johnston SC. The transformational effects of COVID-19 on medical education. JAMA. 2020;324(11):1033-4.

2. Bhutta ZA et al. Education of health professionals for the 21st century: A global independent Commission. Lancet. 2010 Apr 3;375(9721):1137-8.

3. Goldhamer MEJ et al. Can COVID catalyze an educational transformation? Competency-based advancement in a crisis. N Engl J Med. 2020;383:1003-5.

Medicare officials stuck with their plan to increase payments for office visits for primary care and several other specialties that focus on helping patients manage complex conditions such as diabetes. In doing so, Medicare also finalized cuts for other fields, triggering a new wave of protests.

The final version of the 2021 Medicare physician fee schedule was unveiled on the night of Dec. 1. The Centers for Medicare & Medicaid Services posted an unofficial copy of the rule, which will later be published in the Federal Register.

CMS said it completed work on this massive annual review of payments for clinicians later than it usually does because of the demands of the federal response to the COVID-19 pandemic. The 2021 physician fee rule will take effect within a 30-day period instead of the usual 60-day time frame.

The rule, which runs to more than 2,100 pages, makes myriad changes in Medicare policies, including rules on telehealth, and expands the roles of nurse practitioners and physician assistants.

The most contentious item proposed for 2021 was a reshuffling of payments among specialties as part of an overhaul of Medicare’s approach to valuing evaluation and management (E/M) services. There was broader support for other aspects of the E/M overhaul, which are intended to cut some of the administrative hassle clinicians face.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” CMS Administrator Seema Verma said in a statement. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In the final rule, CMS summarized these results of the E/M changes in Table 106. CMS largely stuck with the approach outlined in a draft rule released in August, with minor changes in the amounts of cuts and increases.

Specialties in line for increases under the 2021 final physician fee schedule include allergy/immunology (9%), endocrinology (16%), family practice (13%), general practice (7%), geriatrics (3%), hematology/oncology (14%), internal medicine (4%), nephrology (6%), physician assistants (8%), psychiatry (7%), rheumatology (15%), and urology (8%).

In line for cuts would be anesthesiology (–8%), cardiac surgery (–8%), emergency medicine (–6%), general surgery (–6%), infectious disease (–4%), neurosurgery (–6%), physical/occupational therapy (–9%), plastic surgery (–7%), radiology (–10%), and thoracic surgery (–8%).

CMS had initially set these changes in 2021 pay in motion in the 2020 physician fee schedule. The agency subsequently faced significant opposition to its plans. Many physician groups sought to waive a “budget-neutral” approach to the E/M overhaul, which makes the offsetting of cuts necessary. They argued this would allow increased compensation for clinicians whose practices focus on office visits without requiring offsetting cuts from other fields of medicine.

The American Medical Association is among those urging Congress to prevent or postpone the payment reductions resulting from Medicare’s budget neutrality requirement as applied to the E/M overhaul.

In a Tuesday statement, AMA President Susan R. Bailey, MD, noted that many physicians are facing “substantial economic hardships due to COVID-19.”

By AMA’s calculations, CMS’ planned 2021 E/M overhaul could result in “a shocking reduction of 10.2% to Medicare payment rates,” according to Bailey’s statement. The AMA strongly supports other aspects of the E/M changes CMS finalized, which Bailey said will result in “simpler and more flexible” coding and documentation.

The Surgical Care Coalition, which represents about a dozen medical specialty associations, is asking members of Congress to block the full implementation of the E/M overhaul.

In a Dec. 1 statement, the coalition urged the passage of a bill (HR 8702) that has been introduced in the House by a bipartisan duo of physicians, Rep. Ami Bera, MD (D-Calif.), and Rep. Larry Bucshon, MD (R-Ind.). Their bill would effectively block the cuts from going into effect on January 1, 2021. It would provide an additional Medicare payment for certain services in 2021 and 2022 if the otherwise applicable payment is less than it would have been in 2020.

The Medicare E/M overhaul “was a dangerous policy even before the pandemic, and enacting it during the worst health care crisis in a century is unconscionable. If Congress fails to act, it will further strain a health care system that’s already been pushed to the brink due to the COVID-19 pandemic and undermine patient care,” said John A. Wilson, MD, president of the American Association of Neurological Surgeons, in a statement.

Also backing the Bera-Bucshon bill is the American College of Emergency Physicians. In a statement on Tuesday, ACEP President Mark Rosenberg, DO, MBA, urged Congress to act on this measure.

“Emergency physicians and other health care providers battling on the front lines of the ongoing pandemic are already under unprecedented financial strain as they continue to bear the brunt of COVID-19,” Dr. Rosenberg said. “These cuts would have a devastating impact for the future of emergency medicine and could seriously impede patients’ access to emergency care when they need it most.”
 

“Long overdue”

But there also are champions for the approach CMS took in the E/M overhaul. The influential Medicare Payment Advisory Commission (MedPAC) has argued strongly for keeping the budget-neutral approach to the E/M overhaul.

In an Oct. 2 comment to CMS about the draft 2021 physician fee schedule, MedPAC Chairman Michael E. Chernew, PhD, said this approach would “help rebalance the fee schedule from services that have become overvalued to services that have become undervalued.”

This budget-neutral approach also “will go further in reducing the large gap in compensation between primary care physicians (who had a median income of $243,000 in 2018) and specialists such as surgeons (whose median income was $426,000 in 2018),” Dr. Chernew wrote.

In a Tuesday tweet, Robert B. Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, said CMS had “finalized long overdue payment increases for primary and comprehensive care including an add-in for more complex visits.”

The American Academy of Family Physicians joined ACP in a November 30 letter to congressional leaders, urging them to allow Medicare “to increase investment in primary care, benefiting millions of Medicare patients and the program itself, and reject last minute efforts to prevent these essential and long-overdue changes from going fully into effect on January 1, 2021.”

In the letter, AAFP and ACP and their cosigners argued for a need to address “underinvestment” in primary care by finalizing the E/M overhaul.

“Given that six in ten American adults have a chronic disease and four in ten have two or more chronic conditions, why would we, as a country, accept such an inadequate investment in the very care model that stands to provide maximum value to these patients?” they wrote. “Since we know that individuals with a longitudinal relationship with a primary care physician have better health outcomes and use fewer health care resources, why would we continue to direct money to higher-cost, marginal value services?”

A version of this article originally appeared on Medscape.com.

Medicare officials stuck with their plan to increase payments for office visits for primary care and several other specialties that focus on helping patients manage complex conditions such as diabetes. In doing so, Medicare also finalized cuts for other fields, triggering a new wave of protests.

The final version of the 2021 Medicare physician fee schedule was unveiled on the night of Dec. 1. The Centers for Medicare & Medicaid Services posted an unofficial copy of the rule, which will later be published in the Federal Register.

CMS said it completed work on this massive annual review of payments for clinicians later than it usually does because of the demands of the federal response to the COVID-19 pandemic. The 2021 physician fee rule will take effect within a 30-day period instead of the usual 60-day time frame.

The rule, which runs to more than 2,100 pages, makes myriad changes in Medicare policies, including rules on telehealth, and expands the roles of nurse practitioners and physician assistants.

The most contentious item proposed for 2021 was a reshuffling of payments among specialties as part of an overhaul of Medicare’s approach to valuing evaluation and management (E/M) services. There was broader support for other aspects of the E/M overhaul, which are intended to cut some of the administrative hassle clinicians face.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” CMS Administrator Seema Verma said in a statement. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In the final rule, CMS summarized these results of the E/M changes in Table 106. CMS largely stuck with the approach outlined in a draft rule released in August, with minor changes in the amounts of cuts and increases.

Specialties in line for increases under the 2021 final physician fee schedule include allergy/immunology (9%), endocrinology (16%), family practice (13%), general practice (7%), geriatrics (3%), hematology/oncology (14%), internal medicine (4%), nephrology (6%), physician assistants (8%), psychiatry (7%), rheumatology (15%), and urology (8%).

In line for cuts would be anesthesiology (–8%), cardiac surgery (–8%), emergency medicine (–6%), general surgery (–6%), infectious disease (–4%), neurosurgery (–6%), physical/occupational therapy (–9%), plastic surgery (–7%), radiology (–10%), and thoracic surgery (–8%).

CMS had initially set these changes in 2021 pay in motion in the 2020 physician fee schedule. The agency subsequently faced significant opposition to its plans. Many physician groups sought to waive a “budget-neutral” approach to the E/M overhaul, which makes the offsetting of cuts necessary. They argued this would allow increased compensation for clinicians whose practices focus on office visits without requiring offsetting cuts from other fields of medicine.

The American Medical Association is among those urging Congress to prevent or postpone the payment reductions resulting from Medicare’s budget neutrality requirement as applied to the E/M overhaul.

In a Tuesday statement, AMA President Susan R. Bailey, MD, noted that many physicians are facing “substantial economic hardships due to COVID-19.”

By AMA’s calculations, CMS’ planned 2021 E/M overhaul could result in “a shocking reduction of 10.2% to Medicare payment rates,” according to Bailey’s statement. The AMA strongly supports other aspects of the E/M changes CMS finalized, which Bailey said will result in “simpler and more flexible” coding and documentation.

The Surgical Care Coalition, which represents about a dozen medical specialty associations, is asking members of Congress to block the full implementation of the E/M overhaul.

In a Dec. 1 statement, the coalition urged the passage of a bill (HR 8702) that has been introduced in the House by a bipartisan duo of physicians, Rep. Ami Bera, MD (D-Calif.), and Rep. Larry Bucshon, MD (R-Ind.). Their bill would effectively block the cuts from going into effect on January 1, 2021. It would provide an additional Medicare payment for certain services in 2021 and 2022 if the otherwise applicable payment is less than it would have been in 2020.

The Medicare E/M overhaul “was a dangerous policy even before the pandemic, and enacting it during the worst health care crisis in a century is unconscionable. If Congress fails to act, it will further strain a health care system that’s already been pushed to the brink due to the COVID-19 pandemic and undermine patient care,” said John A. Wilson, MD, president of the American Association of Neurological Surgeons, in a statement.

Also backing the Bera-Bucshon bill is the American College of Emergency Physicians. In a statement on Tuesday, ACEP President Mark Rosenberg, DO, MBA, urged Congress to act on this measure.

“Emergency physicians and other health care providers battling on the front lines of the ongoing pandemic are already under unprecedented financial strain as they continue to bear the brunt of COVID-19,” Dr. Rosenberg said. “These cuts would have a devastating impact for the future of emergency medicine and could seriously impede patients’ access to emergency care when they need it most.”
 

“Long overdue”

But there also are champions for the approach CMS took in the E/M overhaul. The influential Medicare Payment Advisory Commission (MedPAC) has argued strongly for keeping the budget-neutral approach to the E/M overhaul.

In an Oct. 2 comment to CMS about the draft 2021 physician fee schedule, MedPAC Chairman Michael E. Chernew, PhD, said this approach would “help rebalance the fee schedule from services that have become overvalued to services that have become undervalued.”

This budget-neutral approach also “will go further in reducing the large gap in compensation between primary care physicians (who had a median income of $243,000 in 2018) and specialists such as surgeons (whose median income was $426,000 in 2018),” Dr. Chernew wrote.

In a Tuesday tweet, Robert B. Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, said CMS had “finalized long overdue payment increases for primary and comprehensive care including an add-in for more complex visits.”

The American Academy of Family Physicians joined ACP in a November 30 letter to congressional leaders, urging them to allow Medicare “to increase investment in primary care, benefiting millions of Medicare patients and the program itself, and reject last minute efforts to prevent these essential and long-overdue changes from going fully into effect on January 1, 2021.”

In the letter, AAFP and ACP and their cosigners argued for a need to address “underinvestment” in primary care by finalizing the E/M overhaul.

“Given that six in ten American adults have a chronic disease and four in ten have two or more chronic conditions, why would we, as a country, accept such an inadequate investment in the very care model that stands to provide maximum value to these patients?” they wrote. “Since we know that individuals with a longitudinal relationship with a primary care physician have better health outcomes and use fewer health care resources, why would we continue to direct money to higher-cost, marginal value services?”

A version of this article originally appeared on Medscape.com.

Medicare officials stuck with their plan to increase payments for office visits for primary care and several other specialties that focus on helping patients manage complex conditions such as diabetes. In doing so, Medicare also finalized cuts for other fields, triggering a new wave of protests.

The final version of the 2021 Medicare physician fee schedule was unveiled on the night of Dec. 1. The Centers for Medicare & Medicaid Services posted an unofficial copy of the rule, which will later be published in the Federal Register.

CMS said it completed work on this massive annual review of payments for clinicians later than it usually does because of the demands of the federal response to the COVID-19 pandemic. The 2021 physician fee rule will take effect within a 30-day period instead of the usual 60-day time frame.

The rule, which runs to more than 2,100 pages, makes myriad changes in Medicare policies, including rules on telehealth, and expands the roles of nurse practitioners and physician assistants.

The most contentious item proposed for 2021 was a reshuffling of payments among specialties as part of an overhaul of Medicare’s approach to valuing evaluation and management (E/M) services. There was broader support for other aspects of the E/M overhaul, which are intended to cut some of the administrative hassle clinicians face.

“This finalized policy marks the most significant updates to E/M codes in 30 years, reducing burden on doctors imposed by the coding system and rewarding time spent evaluating and managing their patients’ care,” CMS Administrator Seema Verma said in a statement. “In the past, the system has rewarded interventions and procedures over time spent with patients – time taken preventing disease and managing chronic illnesses.”

In the final rule, CMS summarized these results of the E/M changes in Table 106. CMS largely stuck with the approach outlined in a draft rule released in August, with minor changes in the amounts of cuts and increases.

Specialties in line for increases under the 2021 final physician fee schedule include allergy/immunology (9%), endocrinology (16%), family practice (13%), general practice (7%), geriatrics (3%), hematology/oncology (14%), internal medicine (4%), nephrology (6%), physician assistants (8%), psychiatry (7%), rheumatology (15%), and urology (8%).

In line for cuts would be anesthesiology (–8%), cardiac surgery (–8%), emergency medicine (–6%), general surgery (–6%), infectious disease (–4%), neurosurgery (–6%), physical/occupational therapy (–9%), plastic surgery (–7%), radiology (–10%), and thoracic surgery (–8%).

CMS had initially set these changes in 2021 pay in motion in the 2020 physician fee schedule. The agency subsequently faced significant opposition to its plans. Many physician groups sought to waive a “budget-neutral” approach to the E/M overhaul, which makes the offsetting of cuts necessary. They argued this would allow increased compensation for clinicians whose practices focus on office visits without requiring offsetting cuts from other fields of medicine.

The American Medical Association is among those urging Congress to prevent or postpone the payment reductions resulting from Medicare’s budget neutrality requirement as applied to the E/M overhaul.

In a Tuesday statement, AMA President Susan R. Bailey, MD, noted that many physicians are facing “substantial economic hardships due to COVID-19.”

By AMA’s calculations, CMS’ planned 2021 E/M overhaul could result in “a shocking reduction of 10.2% to Medicare payment rates,” according to Bailey’s statement. The AMA strongly supports other aspects of the E/M changes CMS finalized, which Bailey said will result in “simpler and more flexible” coding and documentation.

The Surgical Care Coalition, which represents about a dozen medical specialty associations, is asking members of Congress to block the full implementation of the E/M overhaul.

In a Dec. 1 statement, the coalition urged the passage of a bill (HR 8702) that has been introduced in the House by a bipartisan duo of physicians, Rep. Ami Bera, MD (D-Calif.), and Rep. Larry Bucshon, MD (R-Ind.). Their bill would effectively block the cuts from going into effect on January 1, 2021. It would provide an additional Medicare payment for certain services in 2021 and 2022 if the otherwise applicable payment is less than it would have been in 2020.

The Medicare E/M overhaul “was a dangerous policy even before the pandemic, and enacting it during the worst health care crisis in a century is unconscionable. If Congress fails to act, it will further strain a health care system that’s already been pushed to the brink due to the COVID-19 pandemic and undermine patient care,” said John A. Wilson, MD, president of the American Association of Neurological Surgeons, in a statement.

Also backing the Bera-Bucshon bill is the American College of Emergency Physicians. In a statement on Tuesday, ACEP President Mark Rosenberg, DO, MBA, urged Congress to act on this measure.

“Emergency physicians and other health care providers battling on the front lines of the ongoing pandemic are already under unprecedented financial strain as they continue to bear the brunt of COVID-19,” Dr. Rosenberg said. “These cuts would have a devastating impact for the future of emergency medicine and could seriously impede patients’ access to emergency care when they need it most.”
 

“Long overdue”

But there also are champions for the approach CMS took in the E/M overhaul. The influential Medicare Payment Advisory Commission (MedPAC) has argued strongly for keeping the budget-neutral approach to the E/M overhaul.

In an Oct. 2 comment to CMS about the draft 2021 physician fee schedule, MedPAC Chairman Michael E. Chernew, PhD, said this approach would “help rebalance the fee schedule from services that have become overvalued to services that have become undervalued.”

This budget-neutral approach also “will go further in reducing the large gap in compensation between primary care physicians (who had a median income of $243,000 in 2018) and specialists such as surgeons (whose median income was $426,000 in 2018),” Dr. Chernew wrote.

In a Tuesday tweet, Robert B. Doherty, senior vice president of governmental affairs and public policy for the American College of Physicians, said CMS had “finalized long overdue payment increases for primary and comprehensive care including an add-in for more complex visits.”

The American Academy of Family Physicians joined ACP in a November 30 letter to congressional leaders, urging them to allow Medicare “to increase investment in primary care, benefiting millions of Medicare patients and the program itself, and reject last minute efforts to prevent these essential and long-overdue changes from going fully into effect on January 1, 2021.”

In the letter, AAFP and ACP and their cosigners argued for a need to address “underinvestment” in primary care by finalizing the E/M overhaul.

“Given that six in ten American adults have a chronic disease and four in ten have two or more chronic conditions, why would we, as a country, accept such an inadequate investment in the very care model that stands to provide maximum value to these patients?” they wrote. “Since we know that individuals with a longitudinal relationship with a primary care physician have better health outcomes and use fewer health care resources, why would we continue to direct money to higher-cost, marginal value services?”

A version of this article originally appeared on Medscape.com.