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How to get a position as a physician leader
The best ways to start
It’s been said that physicians tend to fall into leadership roles. Few physicians set out to become leaders, and then one day they realize that they desire to be a leader and an agent for change.
They may be rotating through the chairmanship of a clinical department or the management of a small practice and decide they like the work. In a large organization, doctors get assigned to committees, or specialists agree to run a new service line for a while, and it changes their lives.
Some physicians have a natural aptitude for managerial work. Often, colleagues tell them they are a good fit, but they may still have some reservations. In any case, it’s good to do a bit of soul-searching before taking the leap.
1. Weigh the pluses and minuses of a leadership role
When you stand at the precipice of a totally new career in physician leadership, it’s worthwhile to step back and consider the pluses and minuses of the work.
One plus is that there may be fewer work hours than on the clinical side, but being a physician leader is by no means a 9-to-5 job. In a large organization, a physician on the executive team can be on administrative call – dealing with institutional crises on off-hours – for a length of time. Board and strategic planning retreats tend to occur on weekends, and you may need to attend frequent dinner meetings.
Another plus is that the pay is pretty good. In 2016, physician leaders in large organizations earned an average of $350,000 a year, according to a survey by Cejka Executive Search and the American Association for Physician Leadership (AAPL).1
On the minus side, an executive probably won’t be as beloved as a clinician serving a host of grateful patients. And you will not have the kind of job security that most clinicians have. There may be frequent turnover among health care executives because of change of top leadership, pressure for more profitability, or a host of other reasons.
2. Try on different roles
To decide whether you want to make a career of being a physician leader, it’s useful to try out several different jobs. Volunteer for committees or take on a special project if it’s possible to do so in your organization.
You can also volunteer for posts outside the organization, such as joining the board of your local cancer or heart association or helping them out on a committee. You might volunteer for Little League or a school or civic organization. Your choices are wide open. The goal is to get a feel for directing an organization and whether that fits your lifestyle.
Also, talk to current physician leaders. Contact a cross-section of people, including those who are unhappy with their jobs and those who had to struggle with their new roles. This will give you some good perspective into whether the work is right for you, as well as tips on how to cope.
3. Find a mentor
This is also a good time to find a mentor for your new calling. Choose a seasoned physician leader who can help you over the long haul – someone who can get you up to speed and then advise you during crucial junctures in your career.
Good mentors should be willing to spend the time with you, have your best interests in mind, and be willing to provide honest assessments. They can also help you find opportunities for further learning and professional growth.
Some organizations assign mentors to physicians they want to develop for leadership roles. You can also choose specific mentors to help you in areas where you think you need more work, such as finance, quality improvement, or information systems.
Choose a path
There are many different paths you can take as a physician leader. In large organizations in particular, there are more leadership jobs open to physicians than ever before.
Jobs open to physicians can be found in the areas of clinical quality and safety, population health, managed care, and information technology. You can even look beyond these traditional roles to jobs that don’t usually attract physicians, such as in strategy, innovation, patient experience, and fundraising. In these roles, you are often expected to continue doing some clinical work.
Physician leaders now tend to have more influence than in the past. According to the Cejka-AAPL survey, 61% of physician executives said they had more strategic input currently than in the previous year.
A roster of potential physician leader jobs
1. Executive-level roles
Vice president for medical affairs. This is the traditional role for the physician executive, which involves acting as a liaison with the organization’s physicians. These officers oversee quality of care as well as hiring, training, and performance evaluation of physicians on staff.
Chief medical officer (CMO). This is now the typical term for the highest medical role in the organization. The CMO is part of the C-suite team and participates in governance, strategic planning, and business operation decisions. CMOs may be responsible for supporting value-based strategies and making sure that those strategies are efficient and medically necessary.
Physician-in-chief. This is a new term for the hospital’s top physician, who works with the senior leadership team to maintain standards of care and customer service. The physician-in-chief may also oversee operational efficiency and support organizational transformation.
Chief clinical officer (CCO). CCOs oversee patient engagement and clinical quality outcomes. They may lead initiatives to reduce waste and improve care quality, and they can be involved in implementation of electronic health records (EHRs) and data integration. They may also assist in medical staff development, clinical integration, and physician partnerships.
2. Quality, safety, and research roles
Chief patient safety officer (CPSO). CPSOs oversee the hospital or health system’s patient safety initiatives. Their goal is to reduce medical errors and near-misses.
Chief quality officer (CQO). CQOs are responsible for collecting quality data and supporting patient safety efforts. They advise on quality initiatives and hold clinicians accountable for meeting specific quality indicators. They may also be involved in developing a culture of continuous improvement in the organization.
Chief research officer (CRO). CROs oversee the organization’s research activities, including clinical trials, internal investigator-initiated research programs, and sponsored studies.
3. Technology
Chief medical information officer (CMIO). The CMIO is the information technology (IT) department’s liaison with the clinical staff, working on selection and improvement of EHR systems. The CMIO finds new ways for EHRs to improve healthcare delivery in the organization.
Chief health information officer (CHIO). CHIOs deal with EHR implementation and health informatics. They may report to the chief information officer, the chief operations officer, or another C-suite executive, and they manage health informatics, telehealth, business and clinical intelligence, and predictive analytics initiatives.
Chief technology officer (CTO). CTOs oversee the organization’s technology capabilities. They are responsible for leading the IT team and contributing to the organization’s strategic plan.
4. Jobs not usually for physicians
There are other leadership positions that may not traditionally appeal to physicians but could be worth considering:
Chief experience officer (CXO). This involves evaluating and improving the inpatient experience. CXOs work with physicians and staff on their performance in this area.
Chief innovation officer (CIO). CIOs keep up with industry trends, market disruptions, and new opportunities, and support policy innovations and training initiatives.
Chief transformation officer (CTO). CTOs are responsible for carrying out major changes in the organization. They are supposed to act as role models for change.
5. Salaries for selected physician executives
In addition to placing the average salary for a physician leader at $350,000, the 2016 Cejka-AAPL survey pinpointed average salaries for specific types of physician leaders. Chief medical officers earned $388,000, chief patient safety officers and chief quality officers $375,000, and chief medical information officers $372,500, the survey found.
Several emerging physician leader roles – physician-in-chief, chief strategy officer, chief transformation officer, chief innovation officer, and chief integration officer – earned on average $499,000 a year, according to the survey.
Those jobs provided even higher salaries than the $437,500 reported by Cejka-AAPL for physician CEOs. In comparison, a CEO at a medical group with fewer than 200 physicians had an average salary of $438,500 in 2018, according to SullivanCotter, a health care workforce strategy company.2
Some types of physician leaders have seen unusually high pay raises recently. From 2013 to 2016, the average salary for CMIOs rose 18%, and physician leaders working at the corporate level in a health system saw median compensation rise 67%, the Cejka-AAPL survey found.
Moving ahead
For physician leaders, moving up the ladder often means reinventing yourself. If you’re leaving clinical practice, be sure to develop a solid CV for your new role so that if your leadership position doesn’t work out, you are able to find an appropriate new position.
According to a 2003 assessment, CMOs typically lasted 18-24 months on the job.3
Expect to make mistakes and try to learn from them. If necessary, move on to the next job. There is always a market for seasoned physician executives who took a few punches, learned something from the experience, and found something new.
Start to network
One way to navigate the challenges of a new role is to have a strong network, a group of colleagues and mentors who can help you figure out your path forward. They can serve as sounding boards and contacts for new jobs in an industry that is constantly changing.
A well-functioning network takes constant maintenance.
You can find people for your network by attending a variety of different meetings that physician leaders and other healthcare executives attend. Make a point of keeping their contact information on file and periodically reaching out to them.
Learn in a dyad
Some healthcare organizations assign physician leaders to dyads, where they are matched with nonphysicians who have skills that the physician lacks, such as finance, data management, or organizational politics.
Dyads are less effective when the nonphysician has all the authority and the physician is basically a figurehead. But in an effective dyad, both partners share authority and they can teach skills to each other. While the physician in the dyad brings clinical insight, the nonphysician can provide managerial know-how.
Seek out coaching
There may be points in your leadership career when you become aware of areas where you need improvement. You may have gotten negative feedback on communication skills or political sensitivity. Consider hiring an executive coach; coaches provide concentrated sessions over limited periods of time.
Coaches can also help you prepare for the future. They can help you find ways to promote yourself for new projects or create a network of allies. They also can help you establish yourself as a thought leader in a particular field through writing and speaking engagements.
Some organizations provide in-house coaches. It is worthwhile to take advantage of this benefit. If you need to find a coach on your own, ask mentors or people in your network for recommendations.
Getting to the top
It can take years to rise to the level of the corporate C-suite or even to CEO of a large organization. At the top levels of management, you often have to cut back substantially on clinical work or even give it up entirely.
Becoming CEO of a hospital can be a logical fit for physicians. A physician CEO can relate to doctors on staff, who are a key constituency, and understands what clinical care is all about. However, physician CEOs also need to have a large degree of knowledge about finance, strategy, crisis management, quality improvement, and other nonclinical considerations, not to mention good people skills.
Physicians on boards
Some physicians would rather sit on the board of trustees than take the reins of CEO. Board membership allows you to continue practicing while still having a great deal of influence over the organization. Some physicians hold board seats for many years and enjoy a great deal of respect as the go-to person on clinical care.
Physicians are increasingly serving on the boards of hospitals and health systems. Trustees welcome physicians because they want more input from clinicians in decision-making. They tend to choose physicians who already have executive duties, such as having been a department head.
Which new skills should you learn?
Physician executives often put off learning business and management skills until after being appointed to a leadership position. Even then, they may prefer to take courses focused on a particular topic rather than earn a degree such as master of business administration (MBA).
Learning on the job
A number of executive skills can be learned on the job, such as dealing with quality measures, utilization, billing and coding, disease management, committees, and interpreting data. If you are not in a dyad model, you can ask someone knowledgeable in one of these skills to take you through the steps.
Many physicians could benefit from finance and business courses in order to learn some of the budgetary, accounting, and operational skills required to perform the job optimally.
In a survey of healthcare CEOs, only 30% said their most senior physician leader had a business or medical management degree, and only 21% required a degree.4
Taking classes
Physician executives who want to brush up on a particular topic can “mix and match,” taking short, focused classes on the particular topic whenever they feel the need. In addition to resources offered by SHM, courses are available from organizations such as the AAPL, American Hospital Association, the Medical Group Management Association, or the Healthcare Information and Management Systems Society, to name a few examples.
Pursuing degree programs
Degree programs like MBA, master of public health (MPH), and master of health care administration (MHA) are popular with many physician executives because they get a full overview of needed skills and the potential to earn more money with their new credentials. Physician leaders with an MBA earned 13% more in 2016 than did those with no MBA, according to the Cejka-AAPL survey.
Getting a master’s degree, however, takes time and money. For example, an MBA can cost $20,000 to as much as $100,000.5 MBA, MHA, and MPH degrees take 2 years to complete, while a master of medical management (MMM) and a physician-executive MBA – focusing specifically on what physician leaders need to learn – take 1 year.
Many part-time degree programs are available for those with full-time jobs. You can find them at nearby universities as well as far-off institutions. Much of the coursework is done online, but some on-site work is usually required. You’ll find that working directly with others enriches the learning experience and helps you build your network of colleagues.
Straight MBA or other degree?
In general, degree programs cover finance, communication, strategy, information systems, marketing, organizational behavior, operational management, and quality improvement. Straight MBA programs don’t focus on healthcare, but some physician executives still prefer this route, especially if it involves degrees from prestigious business schools.
MHA, MMM, physician-executive MBA, and other degree programs focused on healthcare are popular with many physicians on the executive track. The MPH is less business-oriented but may be preferable to some because of its focus on population-based health, which fits well with decision-making on health insurance and value-based care.
Conclusion
Physicians need to prepare for leadership because these roles are very different from clinical work. It’s easy to stumble and lose direction without mentors, a network of helpful colleagues, and at least some education in business principles.
Finding a mentor should start early in your new career. A seasoned physician executive can help you understand your options and point out your strengths and shortcomings. Beyond that, concentrated work with an executive coach can help you improve your skills and choose from among the many executive roles that are now available.
You can learn many skills on the job through dyads and other relationships with more seasoned colleagues, or take short classes on particular skills that need to be learned or sharpened. Many physician executives go a step further and get a master’s degree, such as an MBA, MHA, or MMM. This involves a year or two of study, but much of it can be done online.
This article is excerpted from the Medscape Physician Business Academy course “How to become an effective leader.” You can find more information on the course at www.medscape.com/courses/business/100018.
References
1. Cejka Executive Search. 2016 Physician Leadership Compensation Survey results released. Cejka and the American Association for Physician Leadership. Nov 3, 2016.
2. Knowles M. Salaries on upswing for physician executives. Becker’s Hospital Review. Sept 25, 2018.
3. Birrer RB. Becoming a physician executive. Health Progress: Journal of the Catholic Health Association of the United States. Jan-Feb 2003.
4. Witt/Kieffer. Transformation of physician executives: New accountability for quality, performance, integration. Fall 2010.
5. Jurica J. Does an executive salary stand up to a clinical salary? Vital Physician Executive. 2016.
The best ways to start
It’s been said that physicians tend to fall into leadership roles. Few physicians set out to become leaders, and then one day they realize that they desire to be a leader and an agent for change.
They may be rotating through the chairmanship of a clinical department or the management of a small practice and decide they like the work. In a large organization, doctors get assigned to committees, or specialists agree to run a new service line for a while, and it changes their lives.
Some physicians have a natural aptitude for managerial work. Often, colleagues tell them they are a good fit, but they may still have some reservations. In any case, it’s good to do a bit of soul-searching before taking the leap.
1. Weigh the pluses and minuses of a leadership role
When you stand at the precipice of a totally new career in physician leadership, it’s worthwhile to step back and consider the pluses and minuses of the work.
One plus is that there may be fewer work hours than on the clinical side, but being a physician leader is by no means a 9-to-5 job. In a large organization, a physician on the executive team can be on administrative call – dealing with institutional crises on off-hours – for a length of time. Board and strategic planning retreats tend to occur on weekends, and you may need to attend frequent dinner meetings.
Another plus is that the pay is pretty good. In 2016, physician leaders in large organizations earned an average of $350,000 a year, according to a survey by Cejka Executive Search and the American Association for Physician Leadership (AAPL).1
On the minus side, an executive probably won’t be as beloved as a clinician serving a host of grateful patients. And you will not have the kind of job security that most clinicians have. There may be frequent turnover among health care executives because of change of top leadership, pressure for more profitability, or a host of other reasons.
2. Try on different roles
To decide whether you want to make a career of being a physician leader, it’s useful to try out several different jobs. Volunteer for committees or take on a special project if it’s possible to do so in your organization.
You can also volunteer for posts outside the organization, such as joining the board of your local cancer or heart association or helping them out on a committee. You might volunteer for Little League or a school or civic organization. Your choices are wide open. The goal is to get a feel for directing an organization and whether that fits your lifestyle.
Also, talk to current physician leaders. Contact a cross-section of people, including those who are unhappy with their jobs and those who had to struggle with their new roles. This will give you some good perspective into whether the work is right for you, as well as tips on how to cope.
3. Find a mentor
This is also a good time to find a mentor for your new calling. Choose a seasoned physician leader who can help you over the long haul – someone who can get you up to speed and then advise you during crucial junctures in your career.
Good mentors should be willing to spend the time with you, have your best interests in mind, and be willing to provide honest assessments. They can also help you find opportunities for further learning and professional growth.
Some organizations assign mentors to physicians they want to develop for leadership roles. You can also choose specific mentors to help you in areas where you think you need more work, such as finance, quality improvement, or information systems.
Choose a path
There are many different paths you can take as a physician leader. In large organizations in particular, there are more leadership jobs open to physicians than ever before.
Jobs open to physicians can be found in the areas of clinical quality and safety, population health, managed care, and information technology. You can even look beyond these traditional roles to jobs that don’t usually attract physicians, such as in strategy, innovation, patient experience, and fundraising. In these roles, you are often expected to continue doing some clinical work.
Physician leaders now tend to have more influence than in the past. According to the Cejka-AAPL survey, 61% of physician executives said they had more strategic input currently than in the previous year.
A roster of potential physician leader jobs
1. Executive-level roles
Vice president for medical affairs. This is the traditional role for the physician executive, which involves acting as a liaison with the organization’s physicians. These officers oversee quality of care as well as hiring, training, and performance evaluation of physicians on staff.
Chief medical officer (CMO). This is now the typical term for the highest medical role in the organization. The CMO is part of the C-suite team and participates in governance, strategic planning, and business operation decisions. CMOs may be responsible for supporting value-based strategies and making sure that those strategies are efficient and medically necessary.
Physician-in-chief. This is a new term for the hospital’s top physician, who works with the senior leadership team to maintain standards of care and customer service. The physician-in-chief may also oversee operational efficiency and support organizational transformation.
Chief clinical officer (CCO). CCOs oversee patient engagement and clinical quality outcomes. They may lead initiatives to reduce waste and improve care quality, and they can be involved in implementation of electronic health records (EHRs) and data integration. They may also assist in medical staff development, clinical integration, and physician partnerships.
2. Quality, safety, and research roles
Chief patient safety officer (CPSO). CPSOs oversee the hospital or health system’s patient safety initiatives. Their goal is to reduce medical errors and near-misses.
Chief quality officer (CQO). CQOs are responsible for collecting quality data and supporting patient safety efforts. They advise on quality initiatives and hold clinicians accountable for meeting specific quality indicators. They may also be involved in developing a culture of continuous improvement in the organization.
Chief research officer (CRO). CROs oversee the organization’s research activities, including clinical trials, internal investigator-initiated research programs, and sponsored studies.
3. Technology
Chief medical information officer (CMIO). The CMIO is the information technology (IT) department’s liaison with the clinical staff, working on selection and improvement of EHR systems. The CMIO finds new ways for EHRs to improve healthcare delivery in the organization.
Chief health information officer (CHIO). CHIOs deal with EHR implementation and health informatics. They may report to the chief information officer, the chief operations officer, or another C-suite executive, and they manage health informatics, telehealth, business and clinical intelligence, and predictive analytics initiatives.
Chief technology officer (CTO). CTOs oversee the organization’s technology capabilities. They are responsible for leading the IT team and contributing to the organization’s strategic plan.
4. Jobs not usually for physicians
There are other leadership positions that may not traditionally appeal to physicians but could be worth considering:
Chief experience officer (CXO). This involves evaluating and improving the inpatient experience. CXOs work with physicians and staff on their performance in this area.
Chief innovation officer (CIO). CIOs keep up with industry trends, market disruptions, and new opportunities, and support policy innovations and training initiatives.
Chief transformation officer (CTO). CTOs are responsible for carrying out major changes in the organization. They are supposed to act as role models for change.
5. Salaries for selected physician executives
In addition to placing the average salary for a physician leader at $350,000, the 2016 Cejka-AAPL survey pinpointed average salaries for specific types of physician leaders. Chief medical officers earned $388,000, chief patient safety officers and chief quality officers $375,000, and chief medical information officers $372,500, the survey found.
Several emerging physician leader roles – physician-in-chief, chief strategy officer, chief transformation officer, chief innovation officer, and chief integration officer – earned on average $499,000 a year, according to the survey.
Those jobs provided even higher salaries than the $437,500 reported by Cejka-AAPL for physician CEOs. In comparison, a CEO at a medical group with fewer than 200 physicians had an average salary of $438,500 in 2018, according to SullivanCotter, a health care workforce strategy company.2
Some types of physician leaders have seen unusually high pay raises recently. From 2013 to 2016, the average salary for CMIOs rose 18%, and physician leaders working at the corporate level in a health system saw median compensation rise 67%, the Cejka-AAPL survey found.
Moving ahead
For physician leaders, moving up the ladder often means reinventing yourself. If you’re leaving clinical practice, be sure to develop a solid CV for your new role so that if your leadership position doesn’t work out, you are able to find an appropriate new position.
According to a 2003 assessment, CMOs typically lasted 18-24 months on the job.3
Expect to make mistakes and try to learn from them. If necessary, move on to the next job. There is always a market for seasoned physician executives who took a few punches, learned something from the experience, and found something new.
Start to network
One way to navigate the challenges of a new role is to have a strong network, a group of colleagues and mentors who can help you figure out your path forward. They can serve as sounding boards and contacts for new jobs in an industry that is constantly changing.
A well-functioning network takes constant maintenance.
You can find people for your network by attending a variety of different meetings that physician leaders and other healthcare executives attend. Make a point of keeping their contact information on file and periodically reaching out to them.
Learn in a dyad
Some healthcare organizations assign physician leaders to dyads, where they are matched with nonphysicians who have skills that the physician lacks, such as finance, data management, or organizational politics.
Dyads are less effective when the nonphysician has all the authority and the physician is basically a figurehead. But in an effective dyad, both partners share authority and they can teach skills to each other. While the physician in the dyad brings clinical insight, the nonphysician can provide managerial know-how.
Seek out coaching
There may be points in your leadership career when you become aware of areas where you need improvement. You may have gotten negative feedback on communication skills or political sensitivity. Consider hiring an executive coach; coaches provide concentrated sessions over limited periods of time.
Coaches can also help you prepare for the future. They can help you find ways to promote yourself for new projects or create a network of allies. They also can help you establish yourself as a thought leader in a particular field through writing and speaking engagements.
Some organizations provide in-house coaches. It is worthwhile to take advantage of this benefit. If you need to find a coach on your own, ask mentors or people in your network for recommendations.
Getting to the top
It can take years to rise to the level of the corporate C-suite or even to CEO of a large organization. At the top levels of management, you often have to cut back substantially on clinical work or even give it up entirely.
Becoming CEO of a hospital can be a logical fit for physicians. A physician CEO can relate to doctors on staff, who are a key constituency, and understands what clinical care is all about. However, physician CEOs also need to have a large degree of knowledge about finance, strategy, crisis management, quality improvement, and other nonclinical considerations, not to mention good people skills.
Physicians on boards
Some physicians would rather sit on the board of trustees than take the reins of CEO. Board membership allows you to continue practicing while still having a great deal of influence over the organization. Some physicians hold board seats for many years and enjoy a great deal of respect as the go-to person on clinical care.
Physicians are increasingly serving on the boards of hospitals and health systems. Trustees welcome physicians because they want more input from clinicians in decision-making. They tend to choose physicians who already have executive duties, such as having been a department head.
Which new skills should you learn?
Physician executives often put off learning business and management skills until after being appointed to a leadership position. Even then, they may prefer to take courses focused on a particular topic rather than earn a degree such as master of business administration (MBA).
Learning on the job
A number of executive skills can be learned on the job, such as dealing with quality measures, utilization, billing and coding, disease management, committees, and interpreting data. If you are not in a dyad model, you can ask someone knowledgeable in one of these skills to take you through the steps.
Many physicians could benefit from finance and business courses in order to learn some of the budgetary, accounting, and operational skills required to perform the job optimally.
In a survey of healthcare CEOs, only 30% said their most senior physician leader had a business or medical management degree, and only 21% required a degree.4
Taking classes
Physician executives who want to brush up on a particular topic can “mix and match,” taking short, focused classes on the particular topic whenever they feel the need. In addition to resources offered by SHM, courses are available from organizations such as the AAPL, American Hospital Association, the Medical Group Management Association, or the Healthcare Information and Management Systems Society, to name a few examples.
Pursuing degree programs
Degree programs like MBA, master of public health (MPH), and master of health care administration (MHA) are popular with many physician executives because they get a full overview of needed skills and the potential to earn more money with their new credentials. Physician leaders with an MBA earned 13% more in 2016 than did those with no MBA, according to the Cejka-AAPL survey.
Getting a master’s degree, however, takes time and money. For example, an MBA can cost $20,000 to as much as $100,000.5 MBA, MHA, and MPH degrees take 2 years to complete, while a master of medical management (MMM) and a physician-executive MBA – focusing specifically on what physician leaders need to learn – take 1 year.
Many part-time degree programs are available for those with full-time jobs. You can find them at nearby universities as well as far-off institutions. Much of the coursework is done online, but some on-site work is usually required. You’ll find that working directly with others enriches the learning experience and helps you build your network of colleagues.
Straight MBA or other degree?
In general, degree programs cover finance, communication, strategy, information systems, marketing, organizational behavior, operational management, and quality improvement. Straight MBA programs don’t focus on healthcare, but some physician executives still prefer this route, especially if it involves degrees from prestigious business schools.
MHA, MMM, physician-executive MBA, and other degree programs focused on healthcare are popular with many physicians on the executive track. The MPH is less business-oriented but may be preferable to some because of its focus on population-based health, which fits well with decision-making on health insurance and value-based care.
Conclusion
Physicians need to prepare for leadership because these roles are very different from clinical work. It’s easy to stumble and lose direction without mentors, a network of helpful colleagues, and at least some education in business principles.
Finding a mentor should start early in your new career. A seasoned physician executive can help you understand your options and point out your strengths and shortcomings. Beyond that, concentrated work with an executive coach can help you improve your skills and choose from among the many executive roles that are now available.
You can learn many skills on the job through dyads and other relationships with more seasoned colleagues, or take short classes on particular skills that need to be learned or sharpened. Many physician executives go a step further and get a master’s degree, such as an MBA, MHA, or MMM. This involves a year or two of study, but much of it can be done online.
This article is excerpted from the Medscape Physician Business Academy course “How to become an effective leader.” You can find more information on the course at www.medscape.com/courses/business/100018.
References
1. Cejka Executive Search. 2016 Physician Leadership Compensation Survey results released. Cejka and the American Association for Physician Leadership. Nov 3, 2016.
2. Knowles M. Salaries on upswing for physician executives. Becker’s Hospital Review. Sept 25, 2018.
3. Birrer RB. Becoming a physician executive. Health Progress: Journal of the Catholic Health Association of the United States. Jan-Feb 2003.
4. Witt/Kieffer. Transformation of physician executives: New accountability for quality, performance, integration. Fall 2010.
5. Jurica J. Does an executive salary stand up to a clinical salary? Vital Physician Executive. 2016.
The best ways to start
It’s been said that physicians tend to fall into leadership roles. Few physicians set out to become leaders, and then one day they realize that they desire to be a leader and an agent for change.
They may be rotating through the chairmanship of a clinical department or the management of a small practice and decide they like the work. In a large organization, doctors get assigned to committees, or specialists agree to run a new service line for a while, and it changes their lives.
Some physicians have a natural aptitude for managerial work. Often, colleagues tell them they are a good fit, but they may still have some reservations. In any case, it’s good to do a bit of soul-searching before taking the leap.
1. Weigh the pluses and minuses of a leadership role
When you stand at the precipice of a totally new career in physician leadership, it’s worthwhile to step back and consider the pluses and minuses of the work.
One plus is that there may be fewer work hours than on the clinical side, but being a physician leader is by no means a 9-to-5 job. In a large organization, a physician on the executive team can be on administrative call – dealing with institutional crises on off-hours – for a length of time. Board and strategic planning retreats tend to occur on weekends, and you may need to attend frequent dinner meetings.
Another plus is that the pay is pretty good. In 2016, physician leaders in large organizations earned an average of $350,000 a year, according to a survey by Cejka Executive Search and the American Association for Physician Leadership (AAPL).1
On the minus side, an executive probably won’t be as beloved as a clinician serving a host of grateful patients. And you will not have the kind of job security that most clinicians have. There may be frequent turnover among health care executives because of change of top leadership, pressure for more profitability, or a host of other reasons.
2. Try on different roles
To decide whether you want to make a career of being a physician leader, it’s useful to try out several different jobs. Volunteer for committees or take on a special project if it’s possible to do so in your organization.
You can also volunteer for posts outside the organization, such as joining the board of your local cancer or heart association or helping them out on a committee. You might volunteer for Little League or a school or civic organization. Your choices are wide open. The goal is to get a feel for directing an organization and whether that fits your lifestyle.
Also, talk to current physician leaders. Contact a cross-section of people, including those who are unhappy with their jobs and those who had to struggle with their new roles. This will give you some good perspective into whether the work is right for you, as well as tips on how to cope.
3. Find a mentor
This is also a good time to find a mentor for your new calling. Choose a seasoned physician leader who can help you over the long haul – someone who can get you up to speed and then advise you during crucial junctures in your career.
Good mentors should be willing to spend the time with you, have your best interests in mind, and be willing to provide honest assessments. They can also help you find opportunities for further learning and professional growth.
Some organizations assign mentors to physicians they want to develop for leadership roles. You can also choose specific mentors to help you in areas where you think you need more work, such as finance, quality improvement, or information systems.
Choose a path
There are many different paths you can take as a physician leader. In large organizations in particular, there are more leadership jobs open to physicians than ever before.
Jobs open to physicians can be found in the areas of clinical quality and safety, population health, managed care, and information technology. You can even look beyond these traditional roles to jobs that don’t usually attract physicians, such as in strategy, innovation, patient experience, and fundraising. In these roles, you are often expected to continue doing some clinical work.
Physician leaders now tend to have more influence than in the past. According to the Cejka-AAPL survey, 61% of physician executives said they had more strategic input currently than in the previous year.
A roster of potential physician leader jobs
1. Executive-level roles
Vice president for medical affairs. This is the traditional role for the physician executive, which involves acting as a liaison with the organization’s physicians. These officers oversee quality of care as well as hiring, training, and performance evaluation of physicians on staff.
Chief medical officer (CMO). This is now the typical term for the highest medical role in the organization. The CMO is part of the C-suite team and participates in governance, strategic planning, and business operation decisions. CMOs may be responsible for supporting value-based strategies and making sure that those strategies are efficient and medically necessary.
Physician-in-chief. This is a new term for the hospital’s top physician, who works with the senior leadership team to maintain standards of care and customer service. The physician-in-chief may also oversee operational efficiency and support organizational transformation.
Chief clinical officer (CCO). CCOs oversee patient engagement and clinical quality outcomes. They may lead initiatives to reduce waste and improve care quality, and they can be involved in implementation of electronic health records (EHRs) and data integration. They may also assist in medical staff development, clinical integration, and physician partnerships.
2. Quality, safety, and research roles
Chief patient safety officer (CPSO). CPSOs oversee the hospital or health system’s patient safety initiatives. Their goal is to reduce medical errors and near-misses.
Chief quality officer (CQO). CQOs are responsible for collecting quality data and supporting patient safety efforts. They advise on quality initiatives and hold clinicians accountable for meeting specific quality indicators. They may also be involved in developing a culture of continuous improvement in the organization.
Chief research officer (CRO). CROs oversee the organization’s research activities, including clinical trials, internal investigator-initiated research programs, and sponsored studies.
3. Technology
Chief medical information officer (CMIO). The CMIO is the information technology (IT) department’s liaison with the clinical staff, working on selection and improvement of EHR systems. The CMIO finds new ways for EHRs to improve healthcare delivery in the organization.
Chief health information officer (CHIO). CHIOs deal with EHR implementation and health informatics. They may report to the chief information officer, the chief operations officer, or another C-suite executive, and they manage health informatics, telehealth, business and clinical intelligence, and predictive analytics initiatives.
Chief technology officer (CTO). CTOs oversee the organization’s technology capabilities. They are responsible for leading the IT team and contributing to the organization’s strategic plan.
4. Jobs not usually for physicians
There are other leadership positions that may not traditionally appeal to physicians but could be worth considering:
Chief experience officer (CXO). This involves evaluating and improving the inpatient experience. CXOs work with physicians and staff on their performance in this area.
Chief innovation officer (CIO). CIOs keep up with industry trends, market disruptions, and new opportunities, and support policy innovations and training initiatives.
Chief transformation officer (CTO). CTOs are responsible for carrying out major changes in the organization. They are supposed to act as role models for change.
5. Salaries for selected physician executives
In addition to placing the average salary for a physician leader at $350,000, the 2016 Cejka-AAPL survey pinpointed average salaries for specific types of physician leaders. Chief medical officers earned $388,000, chief patient safety officers and chief quality officers $375,000, and chief medical information officers $372,500, the survey found.
Several emerging physician leader roles – physician-in-chief, chief strategy officer, chief transformation officer, chief innovation officer, and chief integration officer – earned on average $499,000 a year, according to the survey.
Those jobs provided even higher salaries than the $437,500 reported by Cejka-AAPL for physician CEOs. In comparison, a CEO at a medical group with fewer than 200 physicians had an average salary of $438,500 in 2018, according to SullivanCotter, a health care workforce strategy company.2
Some types of physician leaders have seen unusually high pay raises recently. From 2013 to 2016, the average salary for CMIOs rose 18%, and physician leaders working at the corporate level in a health system saw median compensation rise 67%, the Cejka-AAPL survey found.
Moving ahead
For physician leaders, moving up the ladder often means reinventing yourself. If you’re leaving clinical practice, be sure to develop a solid CV for your new role so that if your leadership position doesn’t work out, you are able to find an appropriate new position.
According to a 2003 assessment, CMOs typically lasted 18-24 months on the job.3
Expect to make mistakes and try to learn from them. If necessary, move on to the next job. There is always a market for seasoned physician executives who took a few punches, learned something from the experience, and found something new.
Start to network
One way to navigate the challenges of a new role is to have a strong network, a group of colleagues and mentors who can help you figure out your path forward. They can serve as sounding boards and contacts for new jobs in an industry that is constantly changing.
A well-functioning network takes constant maintenance.
You can find people for your network by attending a variety of different meetings that physician leaders and other healthcare executives attend. Make a point of keeping their contact information on file and periodically reaching out to them.
Learn in a dyad
Some healthcare organizations assign physician leaders to dyads, where they are matched with nonphysicians who have skills that the physician lacks, such as finance, data management, or organizational politics.
Dyads are less effective when the nonphysician has all the authority and the physician is basically a figurehead. But in an effective dyad, both partners share authority and they can teach skills to each other. While the physician in the dyad brings clinical insight, the nonphysician can provide managerial know-how.
Seek out coaching
There may be points in your leadership career when you become aware of areas where you need improvement. You may have gotten negative feedback on communication skills or political sensitivity. Consider hiring an executive coach; coaches provide concentrated sessions over limited periods of time.
Coaches can also help you prepare for the future. They can help you find ways to promote yourself for new projects or create a network of allies. They also can help you establish yourself as a thought leader in a particular field through writing and speaking engagements.
Some organizations provide in-house coaches. It is worthwhile to take advantage of this benefit. If you need to find a coach on your own, ask mentors or people in your network for recommendations.
Getting to the top
It can take years to rise to the level of the corporate C-suite or even to CEO of a large organization. At the top levels of management, you often have to cut back substantially on clinical work or even give it up entirely.
Becoming CEO of a hospital can be a logical fit for physicians. A physician CEO can relate to doctors on staff, who are a key constituency, and understands what clinical care is all about. However, physician CEOs also need to have a large degree of knowledge about finance, strategy, crisis management, quality improvement, and other nonclinical considerations, not to mention good people skills.
Physicians on boards
Some physicians would rather sit on the board of trustees than take the reins of CEO. Board membership allows you to continue practicing while still having a great deal of influence over the organization. Some physicians hold board seats for many years and enjoy a great deal of respect as the go-to person on clinical care.
Physicians are increasingly serving on the boards of hospitals and health systems. Trustees welcome physicians because they want more input from clinicians in decision-making. They tend to choose physicians who already have executive duties, such as having been a department head.
Which new skills should you learn?
Physician executives often put off learning business and management skills until after being appointed to a leadership position. Even then, they may prefer to take courses focused on a particular topic rather than earn a degree such as master of business administration (MBA).
Learning on the job
A number of executive skills can be learned on the job, such as dealing with quality measures, utilization, billing and coding, disease management, committees, and interpreting data. If you are not in a dyad model, you can ask someone knowledgeable in one of these skills to take you through the steps.
Many physicians could benefit from finance and business courses in order to learn some of the budgetary, accounting, and operational skills required to perform the job optimally.
In a survey of healthcare CEOs, only 30% said their most senior physician leader had a business or medical management degree, and only 21% required a degree.4
Taking classes
Physician executives who want to brush up on a particular topic can “mix and match,” taking short, focused classes on the particular topic whenever they feel the need. In addition to resources offered by SHM, courses are available from organizations such as the AAPL, American Hospital Association, the Medical Group Management Association, or the Healthcare Information and Management Systems Society, to name a few examples.
Pursuing degree programs
Degree programs like MBA, master of public health (MPH), and master of health care administration (MHA) are popular with many physician executives because they get a full overview of needed skills and the potential to earn more money with their new credentials. Physician leaders with an MBA earned 13% more in 2016 than did those with no MBA, according to the Cejka-AAPL survey.
Getting a master’s degree, however, takes time and money. For example, an MBA can cost $20,000 to as much as $100,000.5 MBA, MHA, and MPH degrees take 2 years to complete, while a master of medical management (MMM) and a physician-executive MBA – focusing specifically on what physician leaders need to learn – take 1 year.
Many part-time degree programs are available for those with full-time jobs. You can find them at nearby universities as well as far-off institutions. Much of the coursework is done online, but some on-site work is usually required. You’ll find that working directly with others enriches the learning experience and helps you build your network of colleagues.
Straight MBA or other degree?
In general, degree programs cover finance, communication, strategy, information systems, marketing, organizational behavior, operational management, and quality improvement. Straight MBA programs don’t focus on healthcare, but some physician executives still prefer this route, especially if it involves degrees from prestigious business schools.
MHA, MMM, physician-executive MBA, and other degree programs focused on healthcare are popular with many physicians on the executive track. The MPH is less business-oriented but may be preferable to some because of its focus on population-based health, which fits well with decision-making on health insurance and value-based care.
Conclusion
Physicians need to prepare for leadership because these roles are very different from clinical work. It’s easy to stumble and lose direction without mentors, a network of helpful colleagues, and at least some education in business principles.
Finding a mentor should start early in your new career. A seasoned physician executive can help you understand your options and point out your strengths and shortcomings. Beyond that, concentrated work with an executive coach can help you improve your skills and choose from among the many executive roles that are now available.
You can learn many skills on the job through dyads and other relationships with more seasoned colleagues, or take short classes on particular skills that need to be learned or sharpened. Many physician executives go a step further and get a master’s degree, such as an MBA, MHA, or MMM. This involves a year or two of study, but much of it can be done online.
This article is excerpted from the Medscape Physician Business Academy course “How to become an effective leader.” You can find more information on the course at www.medscape.com/courses/business/100018.
References
1. Cejka Executive Search. 2016 Physician Leadership Compensation Survey results released. Cejka and the American Association for Physician Leadership. Nov 3, 2016.
2. Knowles M. Salaries on upswing for physician executives. Becker’s Hospital Review. Sept 25, 2018.
3. Birrer RB. Becoming a physician executive. Health Progress: Journal of the Catholic Health Association of the United States. Jan-Feb 2003.
4. Witt/Kieffer. Transformation of physician executives: New accountability for quality, performance, integration. Fall 2010.
5. Jurica J. Does an executive salary stand up to a clinical salary? Vital Physician Executive. 2016.
Only 40% of residents said training prepped them for COVID-19
Most residents who were asked whether their training prepared them for COVID-19 in a Medscape survey said it had not or they weren’t sure.
Whereas 40% said they felt prepared, 30% said they did not feel prepared and 31% answered they were unsure. (Numbers were rounded, so some answers pushed above 100%.)
One quarter have $300,000 or more in student debt
The Medscape Residents Salary & Debt Report 2020, with data collected April 3 to June 1, found that nearly one in four residents (24%) had medical school debt of more than $300,000. Half (49%) had more than $200,000.
The data include answers from 1,659 U.S. medical residents.
For the sixth straight year, female residents were more satisfied with their pay than were their male colleagues. This year the satisfaction gap was 45% female compared with 42% male. That imbalance came despite their making nearly the same pay overall ($63,700 for men and $63,000 for women).
Among practicing physicians, the pay gap is much wider: Men make 25% more in primary care and 31% more in specialties.
Ten percent thought they should earn 76%-100% more.
For those not satisfied with pay, the top reasons were feeling the pay was too low for the hours worked (81%) or too low compared with other medical staff, such as physician assistants (PAs) or nurses (77% chose that answer).
As for hours worked, 31% of residents reported they spend more than 60 hours/week seeing patients.
The top-paying specialties, averaging $69,500, were allergy and immunology, hematology, plastic surgery, aesthetic medicine, rheumatology, and specialized surgery. The lowest paid were family medicine residents at $58,500.
In primary care, overall, most residents said they planned to specialize. Only 47% planned to continue to work in primary care. Male residents were much more likely to say they will subspecialize than were their female colleagues (52% vs. 35%).
More than 90% of residents say future pay has influenced their choice of specialty, though more men than women felt that way (93% vs. 86%).
Good relationships with others
Overall, residents reported good relationships with attending physicians and nurses.
Most (88%) said they had good or very good relationships with attending physicians, 10% said the relationships were fair, and 2% said they were poor.
In addition, 89% of residents said the amount of supervision was appropriate, 4% said there was too much, and 7% said there was too little.
Relationships with nurses/PAs were slightly less positive overall: Eighty-two percent reported good or very good relationships with nurses/PAs, 15% said those relationships were fair, and 3% said they were poor.
One respondent said: “Our relationships could be better, but I think everyone is just overwhelmed with COVID-19, so emotions are heightened.”
Another said: “It takes time to earn the respect from nurses.”
Seventy-seven percent said they were satisfied with their learning experience overall, 12% were neutral on the question, and 11% said they were dissatisfied or very dissatisfied.
Work-life balance is the top concern
Work-life balance continues to be the top concern for residents. More than one-quarter (27%) in residency years 1 through 4 listed that as the top concern, and even more (32%) of those in years 5 through 8 agreed.
That was followed by demands on time and fear of failure or making a serious mistake.
The survey indicates that benefit packages for residents have stayed much the same over the past 2 years with health insurance and paid time off for sick leave, vacation, and personal time most commonly reported at 89% and 87%, respectively.
Much less common were benefits including commuter assistance (parking, public transportation) at 24%, housing allowance (8%), and child care (4%).
The vast majority of residents reported doing scut work (unskilled tasks): More than half (54%) reported doing 1-10 hours/week and 22% did 11-20 hours/week. Regardless of the number of hours, however, 62% said the time spent performing these tasks was appropriate.
A version of this article originally appeared on Medscape.com.
Most residents who were asked whether their training prepared them for COVID-19 in a Medscape survey said it had not or they weren’t sure.
Whereas 40% said they felt prepared, 30% said they did not feel prepared and 31% answered they were unsure. (Numbers were rounded, so some answers pushed above 100%.)
One quarter have $300,000 or more in student debt
The Medscape Residents Salary & Debt Report 2020, with data collected April 3 to June 1, found that nearly one in four residents (24%) had medical school debt of more than $300,000. Half (49%) had more than $200,000.
The data include answers from 1,659 U.S. medical residents.
For the sixth straight year, female residents were more satisfied with their pay than were their male colleagues. This year the satisfaction gap was 45% female compared with 42% male. That imbalance came despite their making nearly the same pay overall ($63,700 for men and $63,000 for women).
Among practicing physicians, the pay gap is much wider: Men make 25% more in primary care and 31% more in specialties.
Ten percent thought they should earn 76%-100% more.
For those not satisfied with pay, the top reasons were feeling the pay was too low for the hours worked (81%) or too low compared with other medical staff, such as physician assistants (PAs) or nurses (77% chose that answer).
As for hours worked, 31% of residents reported they spend more than 60 hours/week seeing patients.
The top-paying specialties, averaging $69,500, were allergy and immunology, hematology, plastic surgery, aesthetic medicine, rheumatology, and specialized surgery. The lowest paid were family medicine residents at $58,500.
In primary care, overall, most residents said they planned to specialize. Only 47% planned to continue to work in primary care. Male residents were much more likely to say they will subspecialize than were their female colleagues (52% vs. 35%).
More than 90% of residents say future pay has influenced their choice of specialty, though more men than women felt that way (93% vs. 86%).
Good relationships with others
Overall, residents reported good relationships with attending physicians and nurses.
Most (88%) said they had good or very good relationships with attending physicians, 10% said the relationships were fair, and 2% said they were poor.
In addition, 89% of residents said the amount of supervision was appropriate, 4% said there was too much, and 7% said there was too little.
Relationships with nurses/PAs were slightly less positive overall: Eighty-two percent reported good or very good relationships with nurses/PAs, 15% said those relationships were fair, and 3% said they were poor.
One respondent said: “Our relationships could be better, but I think everyone is just overwhelmed with COVID-19, so emotions are heightened.”
Another said: “It takes time to earn the respect from nurses.”
Seventy-seven percent said they were satisfied with their learning experience overall, 12% were neutral on the question, and 11% said they were dissatisfied or very dissatisfied.
Work-life balance is the top concern
Work-life balance continues to be the top concern for residents. More than one-quarter (27%) in residency years 1 through 4 listed that as the top concern, and even more (32%) of those in years 5 through 8 agreed.
That was followed by demands on time and fear of failure or making a serious mistake.
The survey indicates that benefit packages for residents have stayed much the same over the past 2 years with health insurance and paid time off for sick leave, vacation, and personal time most commonly reported at 89% and 87%, respectively.
Much less common were benefits including commuter assistance (parking, public transportation) at 24%, housing allowance (8%), and child care (4%).
The vast majority of residents reported doing scut work (unskilled tasks): More than half (54%) reported doing 1-10 hours/week and 22% did 11-20 hours/week. Regardless of the number of hours, however, 62% said the time spent performing these tasks was appropriate.
A version of this article originally appeared on Medscape.com.
Most residents who were asked whether their training prepared them for COVID-19 in a Medscape survey said it had not or they weren’t sure.
Whereas 40% said they felt prepared, 30% said they did not feel prepared and 31% answered they were unsure. (Numbers were rounded, so some answers pushed above 100%.)
One quarter have $300,000 or more in student debt
The Medscape Residents Salary & Debt Report 2020, with data collected April 3 to June 1, found that nearly one in four residents (24%) had medical school debt of more than $300,000. Half (49%) had more than $200,000.
The data include answers from 1,659 U.S. medical residents.
For the sixth straight year, female residents were more satisfied with their pay than were their male colleagues. This year the satisfaction gap was 45% female compared with 42% male. That imbalance came despite their making nearly the same pay overall ($63,700 for men and $63,000 for women).
Among practicing physicians, the pay gap is much wider: Men make 25% more in primary care and 31% more in specialties.
Ten percent thought they should earn 76%-100% more.
For those not satisfied with pay, the top reasons were feeling the pay was too low for the hours worked (81%) or too low compared with other medical staff, such as physician assistants (PAs) or nurses (77% chose that answer).
As for hours worked, 31% of residents reported they spend more than 60 hours/week seeing patients.
The top-paying specialties, averaging $69,500, were allergy and immunology, hematology, plastic surgery, aesthetic medicine, rheumatology, and specialized surgery. The lowest paid were family medicine residents at $58,500.
In primary care, overall, most residents said they planned to specialize. Only 47% planned to continue to work in primary care. Male residents were much more likely to say they will subspecialize than were their female colleagues (52% vs. 35%).
More than 90% of residents say future pay has influenced their choice of specialty, though more men than women felt that way (93% vs. 86%).
Good relationships with others
Overall, residents reported good relationships with attending physicians and nurses.
Most (88%) said they had good or very good relationships with attending physicians, 10% said the relationships were fair, and 2% said they were poor.
In addition, 89% of residents said the amount of supervision was appropriate, 4% said there was too much, and 7% said there was too little.
Relationships with nurses/PAs were slightly less positive overall: Eighty-two percent reported good or very good relationships with nurses/PAs, 15% said those relationships were fair, and 3% said they were poor.
One respondent said: “Our relationships could be better, but I think everyone is just overwhelmed with COVID-19, so emotions are heightened.”
Another said: “It takes time to earn the respect from nurses.”
Seventy-seven percent said they were satisfied with their learning experience overall, 12% were neutral on the question, and 11% said they were dissatisfied or very dissatisfied.
Work-life balance is the top concern
Work-life balance continues to be the top concern for residents. More than one-quarter (27%) in residency years 1 through 4 listed that as the top concern, and even more (32%) of those in years 5 through 8 agreed.
That was followed by demands on time and fear of failure or making a serious mistake.
The survey indicates that benefit packages for residents have stayed much the same over the past 2 years with health insurance and paid time off for sick leave, vacation, and personal time most commonly reported at 89% and 87%, respectively.
Much less common were benefits including commuter assistance (parking, public transportation) at 24%, housing allowance (8%), and child care (4%).
The vast majority of residents reported doing scut work (unskilled tasks): More than half (54%) reported doing 1-10 hours/week and 22% did 11-20 hours/week. Regardless of the number of hours, however, 62% said the time spent performing these tasks was appropriate.
A version of this article originally appeared on Medscape.com.
Hospitalists share work-parent experience during pandemic
The week of March 13, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, got word that schools were closing because of COVID-19.
“My first thought was, ‘You’re kidding, right?’ ” she said. That was the start of a series of reactions that included denial and bargaining and, finally, some semblance of acceptance.
In a session at HM20 Virtual, hosted by the Society of Hospital Medicine, she and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, described the complicated logistics and emotional and psychological strain that has come from working during a time of such great health care need while balancing home responsibilities and parenting.
At the time schools closed, Dr. Alfandre said, he was busy with clinical work while his wife’s work as an academic psychiatrist, including research activities, stopped for a time, allowing her to manage many of the family duties. Ever since her work picked back up, though, it’s been a juggling act.
“Our roles were dynamic and changing, sometimes week to week,” he said. “It was quite a shock to the system.”
Well before the pandemic struck, Dr. Nye and Dr. Alfandre had been scheduled to talk during the annual conference about work-parenting challenges. The pandemic has further underscored those challenges, they said. although they did make suggestions in that vein.
Child care and odd hours always have been a challenge for hospitalists, they said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.
“And then, of course, there are those ever-important baseball games and ballet recitals and any number of school-related activities to help support your kids,” Dr. Nye said.
COVID-19 has brought a new degree of strain, she said. There is the concern that hospitalists’ very work brings a higher infection risk to their children. Extra work responsibilities have brought on guilt about perhaps not doing a well enough job helping their children with schoolwork “without having any definition of what ‘well enough’ actually looks like.” At the same time, she said, she’s felt “incredibly grateful to have a stable job.
“There is this spectrum of guilt and gratitude that is constant – it’s an undulating, never-stopping pendulum,” she said.
Dr. Alfandre noted that it was a “tremendously proud moment” to have people cheering for his colleagues and him at shift change in New York. Still, after several days off, he “felt guilty that I wasn’t in the hospital.”
Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.
Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.
At work, her center seems to be in a constant state of instability – they’re either dealing with a surge or a reopening.
“It just goes on and on and on and on,” she said. “I find it overwhelming.”
Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other.
“It’s really about cooperation with your partner,” he said. “I really think this is the most important aspect.”
He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.
“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.
When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.
“I feel like sharing that part of our job to our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”
Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.
The week of March 13, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, got word that schools were closing because of COVID-19.
“My first thought was, ‘You’re kidding, right?’ ” she said. That was the start of a series of reactions that included denial and bargaining and, finally, some semblance of acceptance.
In a session at HM20 Virtual, hosted by the Society of Hospital Medicine, she and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, described the complicated logistics and emotional and psychological strain that has come from working during a time of such great health care need while balancing home responsibilities and parenting.
At the time schools closed, Dr. Alfandre said, he was busy with clinical work while his wife’s work as an academic psychiatrist, including research activities, stopped for a time, allowing her to manage many of the family duties. Ever since her work picked back up, though, it’s been a juggling act.
“Our roles were dynamic and changing, sometimes week to week,” he said. “It was quite a shock to the system.”
Well before the pandemic struck, Dr. Nye and Dr. Alfandre had been scheduled to talk during the annual conference about work-parenting challenges. The pandemic has further underscored those challenges, they said. although they did make suggestions in that vein.
Child care and odd hours always have been a challenge for hospitalists, they said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.
“And then, of course, there are those ever-important baseball games and ballet recitals and any number of school-related activities to help support your kids,” Dr. Nye said.
COVID-19 has brought a new degree of strain, she said. There is the concern that hospitalists’ very work brings a higher infection risk to their children. Extra work responsibilities have brought on guilt about perhaps not doing a well enough job helping their children with schoolwork “without having any definition of what ‘well enough’ actually looks like.” At the same time, she said, she’s felt “incredibly grateful to have a stable job.
“There is this spectrum of guilt and gratitude that is constant – it’s an undulating, never-stopping pendulum,” she said.
Dr. Alfandre noted that it was a “tremendously proud moment” to have people cheering for his colleagues and him at shift change in New York. Still, after several days off, he “felt guilty that I wasn’t in the hospital.”
Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.
Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.
At work, her center seems to be in a constant state of instability – they’re either dealing with a surge or a reopening.
“It just goes on and on and on and on,” she said. “I find it overwhelming.”
Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other.
“It’s really about cooperation with your partner,” he said. “I really think this is the most important aspect.”
He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.
“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.
When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.
“I feel like sharing that part of our job to our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”
Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.
The week of March 13, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, got word that schools were closing because of COVID-19.
“My first thought was, ‘You’re kidding, right?’ ” she said. That was the start of a series of reactions that included denial and bargaining and, finally, some semblance of acceptance.
In a session at HM20 Virtual, hosted by the Society of Hospital Medicine, she and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, described the complicated logistics and emotional and psychological strain that has come from working during a time of such great health care need while balancing home responsibilities and parenting.
At the time schools closed, Dr. Alfandre said, he was busy with clinical work while his wife’s work as an academic psychiatrist, including research activities, stopped for a time, allowing her to manage many of the family duties. Ever since her work picked back up, though, it’s been a juggling act.
“Our roles were dynamic and changing, sometimes week to week,” he said. “It was quite a shock to the system.”
Well before the pandemic struck, Dr. Nye and Dr. Alfandre had been scheduled to talk during the annual conference about work-parenting challenges. The pandemic has further underscored those challenges, they said. although they did make suggestions in that vein.
Child care and odd hours always have been a challenge for hospitalists, they said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.
“And then, of course, there are those ever-important baseball games and ballet recitals and any number of school-related activities to help support your kids,” Dr. Nye said.
COVID-19 has brought a new degree of strain, she said. There is the concern that hospitalists’ very work brings a higher infection risk to their children. Extra work responsibilities have brought on guilt about perhaps not doing a well enough job helping their children with schoolwork “without having any definition of what ‘well enough’ actually looks like.” At the same time, she said, she’s felt “incredibly grateful to have a stable job.
“There is this spectrum of guilt and gratitude that is constant – it’s an undulating, never-stopping pendulum,” she said.
Dr. Alfandre noted that it was a “tremendously proud moment” to have people cheering for his colleagues and him at shift change in New York. Still, after several days off, he “felt guilty that I wasn’t in the hospital.”
Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.
Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.
At work, her center seems to be in a constant state of instability – they’re either dealing with a surge or a reopening.
“It just goes on and on and on and on,” she said. “I find it overwhelming.”
Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other.
“It’s really about cooperation with your partner,” he said. “I really think this is the most important aspect.”
He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.
“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.
When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.
“I feel like sharing that part of our job to our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”
Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.
FROM HM20 VIRTUAL
Health disparities training falls short for internal medicine residents
Less than half of internal medicine residency program directors report formal curricula on the topic of health disparities, according to findings of a survey of medical directors and residents across the United States.
Despite recommendations from the Institute of Medicine going back to 2002 calling for increased education on the topic for health care providers, data from a 2012 survey showed that only 17% of internal medicine programs had a health disparities curriculum, wrote Denise M. Dupras, MD, of the Mayo Medical School, Rochester, Minn., and colleagues.
To describe internal medicine residency training programs’ curricula and educational experiences on health disparities and to determine residents’ perceptions of training, the researchers designed a cross-sectional survey study including 227 program directors and 22,723 internal medicine residents. The survey was conducted from August to November 2015.
Overall, 91 program directors (40%) reported a curriculum in health disparities, but only 16 of them described the quality of their education as very good or excellent. In 56% of the programs, outcomes of the curriculum were not measured.
A majority (90%) of the programs included racial/ethnic diversity and socioeconomic status in their curricula, 58% included information about limited English proficiency, and 53% included information about gender identity and sexual orientation.
Reported barriers to curriculum development in 132 programs that did not have a health disparities curriculum included lack of time in the current curriculum, insufficient faculty skill to teach the topic, lack of institutional support, and lack of faculty interest, the researchers noted.
A total of 13,251 residents (70%) reported receiving some training in caring for patients at risk for health disparities over 3 years of training, and 10,494 (80%) of these rated the quality as very good or excellent. “Residents who cared for a larger proportion of underserved patients perceived that they received health disparities training at a higher rate,” the researchers wrote. However, increased care of at-risk populations does not necessarily translate into increased knowledge and skills. “Our finding that residents’ rating of the quality of their training was not associated with the presence of a curriculum in health disparities in their program also raises a concern that perceptions may overestimate the acquisition of needed skills,” they added.
The major limitation of the study was “that residents were not asked directly if they were exposed to a curriculum in health disparities but rather if they received training in the care of patients who would be at risk, which raises the concern that we cannot distinguish between their recognition of a formal and informal curriculum,” the researchers noted. In addition, the survey could not confirm that program directors were aware of all training. “Furthermore, because the survey items were embedded in larger program director survey, we were limited in the ability to ask them to define more specifically the components of their health disparities curricula,” they wrote.
However, the results were strengthened by the large and comprehensive study population, and highlight not only the need for standardized health disparities curricula, but also the need for research to determine the most effective domains for such curricula in graduate medical education, they emphasized.
“There are opportunities to explore partnerships among residencies, institutional clinical practices, and communities for productive collaborations around disparities-related quality improvement projects to address gaps in health care that are specific to the populations they serve,” they concluded.
The surveys were conducted in 2015 and the comparative work in 2018, prior to the COVID-19 pandemic and the subsequent increased concerns about disparities in health care, Dr. Dupras said in an interview.
“We conducted the survey because we recognized that health disparities were still prevalent in our society despite calls to improve the education of our learners to address them. We wanted to determine what our programs were providing for educational curriculum and what our learners were experiencing,” she said.
“We did not know what the surveys would show, so I cannot say that we were surprised by the findings,” said Dr. Dupras. “One of the challenges in interpreting our results is inherent in studies that rely on surveys. We cannot know how those filling out the surveys interpret the questions.” The study results yield several messages.
“First, residency training programs have opportunities to do a better job in developing educational opportunities related to health disparities; second, residents learn in the context of care and we must optimize education around these experiences; third, every patient is different. It is time to move towards cultural humility, since the risk for disparities is not associated with one patient characteristic, but composed of multiple factors,” she said.
“Given that 5 years has passed since our original survey, it would be important to repeat the survey and consider expanding it to include other training programs that provide frontline care, such as family medicine and pediatrics,” Dr. Dupras noted.
Dr. Dupras and colleagues had no financial conflicts to disclose.
SOURCE: Dupras DM et al. JAMA Netw Open. 2020 Aug 10. doi: 10.1001/jamanetworkopen.2020.12757.
Less than half of internal medicine residency program directors report formal curricula on the topic of health disparities, according to findings of a survey of medical directors and residents across the United States.
Despite recommendations from the Institute of Medicine going back to 2002 calling for increased education on the topic for health care providers, data from a 2012 survey showed that only 17% of internal medicine programs had a health disparities curriculum, wrote Denise M. Dupras, MD, of the Mayo Medical School, Rochester, Minn., and colleagues.
To describe internal medicine residency training programs’ curricula and educational experiences on health disparities and to determine residents’ perceptions of training, the researchers designed a cross-sectional survey study including 227 program directors and 22,723 internal medicine residents. The survey was conducted from August to November 2015.
Overall, 91 program directors (40%) reported a curriculum in health disparities, but only 16 of them described the quality of their education as very good or excellent. In 56% of the programs, outcomes of the curriculum were not measured.
A majority (90%) of the programs included racial/ethnic diversity and socioeconomic status in their curricula, 58% included information about limited English proficiency, and 53% included information about gender identity and sexual orientation.
Reported barriers to curriculum development in 132 programs that did not have a health disparities curriculum included lack of time in the current curriculum, insufficient faculty skill to teach the topic, lack of institutional support, and lack of faculty interest, the researchers noted.
A total of 13,251 residents (70%) reported receiving some training in caring for patients at risk for health disparities over 3 years of training, and 10,494 (80%) of these rated the quality as very good or excellent. “Residents who cared for a larger proportion of underserved patients perceived that they received health disparities training at a higher rate,” the researchers wrote. However, increased care of at-risk populations does not necessarily translate into increased knowledge and skills. “Our finding that residents’ rating of the quality of their training was not associated with the presence of a curriculum in health disparities in their program also raises a concern that perceptions may overestimate the acquisition of needed skills,” they added.
The major limitation of the study was “that residents were not asked directly if they were exposed to a curriculum in health disparities but rather if they received training in the care of patients who would be at risk, which raises the concern that we cannot distinguish between their recognition of a formal and informal curriculum,” the researchers noted. In addition, the survey could not confirm that program directors were aware of all training. “Furthermore, because the survey items were embedded in larger program director survey, we were limited in the ability to ask them to define more specifically the components of their health disparities curricula,” they wrote.
However, the results were strengthened by the large and comprehensive study population, and highlight not only the need for standardized health disparities curricula, but also the need for research to determine the most effective domains for such curricula in graduate medical education, they emphasized.
“There are opportunities to explore partnerships among residencies, institutional clinical practices, and communities for productive collaborations around disparities-related quality improvement projects to address gaps in health care that are specific to the populations they serve,” they concluded.
The surveys were conducted in 2015 and the comparative work in 2018, prior to the COVID-19 pandemic and the subsequent increased concerns about disparities in health care, Dr. Dupras said in an interview.
“We conducted the survey because we recognized that health disparities were still prevalent in our society despite calls to improve the education of our learners to address them. We wanted to determine what our programs were providing for educational curriculum and what our learners were experiencing,” she said.
“We did not know what the surveys would show, so I cannot say that we were surprised by the findings,” said Dr. Dupras. “One of the challenges in interpreting our results is inherent in studies that rely on surveys. We cannot know how those filling out the surveys interpret the questions.” The study results yield several messages.
“First, residency training programs have opportunities to do a better job in developing educational opportunities related to health disparities; second, residents learn in the context of care and we must optimize education around these experiences; third, every patient is different. It is time to move towards cultural humility, since the risk for disparities is not associated with one patient characteristic, but composed of multiple factors,” she said.
“Given that 5 years has passed since our original survey, it would be important to repeat the survey and consider expanding it to include other training programs that provide frontline care, such as family medicine and pediatrics,” Dr. Dupras noted.
Dr. Dupras and colleagues had no financial conflicts to disclose.
SOURCE: Dupras DM et al. JAMA Netw Open. 2020 Aug 10. doi: 10.1001/jamanetworkopen.2020.12757.
Less than half of internal medicine residency program directors report formal curricula on the topic of health disparities, according to findings of a survey of medical directors and residents across the United States.
Despite recommendations from the Institute of Medicine going back to 2002 calling for increased education on the topic for health care providers, data from a 2012 survey showed that only 17% of internal medicine programs had a health disparities curriculum, wrote Denise M. Dupras, MD, of the Mayo Medical School, Rochester, Minn., and colleagues.
To describe internal medicine residency training programs’ curricula and educational experiences on health disparities and to determine residents’ perceptions of training, the researchers designed a cross-sectional survey study including 227 program directors and 22,723 internal medicine residents. The survey was conducted from August to November 2015.
Overall, 91 program directors (40%) reported a curriculum in health disparities, but only 16 of them described the quality of their education as very good or excellent. In 56% of the programs, outcomes of the curriculum were not measured.
A majority (90%) of the programs included racial/ethnic diversity and socioeconomic status in their curricula, 58% included information about limited English proficiency, and 53% included information about gender identity and sexual orientation.
Reported barriers to curriculum development in 132 programs that did not have a health disparities curriculum included lack of time in the current curriculum, insufficient faculty skill to teach the topic, lack of institutional support, and lack of faculty interest, the researchers noted.
A total of 13,251 residents (70%) reported receiving some training in caring for patients at risk for health disparities over 3 years of training, and 10,494 (80%) of these rated the quality as very good or excellent. “Residents who cared for a larger proportion of underserved patients perceived that they received health disparities training at a higher rate,” the researchers wrote. However, increased care of at-risk populations does not necessarily translate into increased knowledge and skills. “Our finding that residents’ rating of the quality of their training was not associated with the presence of a curriculum in health disparities in their program also raises a concern that perceptions may overestimate the acquisition of needed skills,” they added.
The major limitation of the study was “that residents were not asked directly if they were exposed to a curriculum in health disparities but rather if they received training in the care of patients who would be at risk, which raises the concern that we cannot distinguish between their recognition of a formal and informal curriculum,” the researchers noted. In addition, the survey could not confirm that program directors were aware of all training. “Furthermore, because the survey items were embedded in larger program director survey, we were limited in the ability to ask them to define more specifically the components of their health disparities curricula,” they wrote.
However, the results were strengthened by the large and comprehensive study population, and highlight not only the need for standardized health disparities curricula, but also the need for research to determine the most effective domains for such curricula in graduate medical education, they emphasized.
“There are opportunities to explore partnerships among residencies, institutional clinical practices, and communities for productive collaborations around disparities-related quality improvement projects to address gaps in health care that are specific to the populations they serve,” they concluded.
The surveys were conducted in 2015 and the comparative work in 2018, prior to the COVID-19 pandemic and the subsequent increased concerns about disparities in health care, Dr. Dupras said in an interview.
“We conducted the survey because we recognized that health disparities were still prevalent in our society despite calls to improve the education of our learners to address them. We wanted to determine what our programs were providing for educational curriculum and what our learners were experiencing,” she said.
“We did not know what the surveys would show, so I cannot say that we were surprised by the findings,” said Dr. Dupras. “One of the challenges in interpreting our results is inherent in studies that rely on surveys. We cannot know how those filling out the surveys interpret the questions.” The study results yield several messages.
“First, residency training programs have opportunities to do a better job in developing educational opportunities related to health disparities; second, residents learn in the context of care and we must optimize education around these experiences; third, every patient is different. It is time to move towards cultural humility, since the risk for disparities is not associated with one patient characteristic, but composed of multiple factors,” she said.
“Given that 5 years has passed since our original survey, it would be important to repeat the survey and consider expanding it to include other training programs that provide frontline care, such as family medicine and pediatrics,” Dr. Dupras noted.
Dr. Dupras and colleagues had no financial conflicts to disclose.
SOURCE: Dupras DM et al. JAMA Netw Open. 2020 Aug 10. doi: 10.1001/jamanetworkopen.2020.12757.
FROM JAMA NETWORK OPEN
Immigrant hospitalist dilemma takes stage at HM20 Virtual
Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.
Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.
“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.
In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.
The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.
“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.
Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.
“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.
Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)
Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.
“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.
“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
SHM advocacy on immigration issues
SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.
The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:
The Fairness for High Skilled Immigrants Act
- This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
- This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.
The Conrad State 30 Physician Reauthorization Act
- This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
The Healthcare Workforce Resilience Act
- This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
- This legislation will only be in effect for the duration of the COVID-19 public health emergency.
To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.
Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.
“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.
In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.
The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.
“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.
Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.
“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.
Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)
Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.
“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.
“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
SHM advocacy on immigration issues
SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.
The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:
The Fairness for High Skilled Immigrants Act
- This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
- This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.
The Conrad State 30 Physician Reauthorization Act
- This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
The Healthcare Workforce Resilience Act
- This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
- This legislation will only be in effect for the duration of the COVID-19 public health emergency.
To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.
Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.
“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.
In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.
The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.
“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.
Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.
“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.
Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)
Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.
“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.
“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
SHM advocacy on immigration issues
SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.
The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:
The Fairness for High Skilled Immigrants Act
- This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
- This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.
The Conrad State 30 Physician Reauthorization Act
- This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
The Healthcare Workforce Resilience Act
- This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
- This legislation will only be in effect for the duration of the COVID-19 public health emergency.
To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
Reflections from PHM’s chief fellow
The education of a new generation of subspecialists
Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.
In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.
At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.
While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.1 However, many chief residents feel their administrative roles outweigh their educational ones.2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.
The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.4
However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.5 With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.
National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?
As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.
This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.
Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.
At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.
One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.6
We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.
Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.
Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.
References
1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.
2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.
3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.
4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.
5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.
6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.
The education of a new generation of subspecialists
The education of a new generation of subspecialists
Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.
In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.
At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.
While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.1 However, many chief residents feel their administrative roles outweigh their educational ones.2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.
The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.4
However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.5 With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.
National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?
As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.
This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.
Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.
At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.
One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.6
We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.
Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.
Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.
References
1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.
2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.
3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.
4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.
5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.
6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.
Editor’s note: The Hospitalist is excited to debut a quarterly Pediatric Hospital Medicine Fellows column with this article by pediatric hospitalist Dr. Adam Cohen.
In June 2019, I was offered the new role of chief fellow of pediatric hospital medicine at Baylor College of Medicine and Texas Children’s Hospital, both in Houston. After messaging colleagues and friends at PHM fellowships across the country, I discovered that I wasn’t only Baylor’s first chief fellow of PHM, but I was the only chief fellow of PHM in the nation.
At first, this seemed to be a daunting prospect that left me wondering what my experiences would be like. However, as any good academician knows, the only way to properly answer a question with such existential considerations is a literature review.
While the role of chief fellow exists in other pediatric subspecialty fellowships, the literature on this role is not yet developed. I focused my literature review on using the chief resident role as a surrogate. The chief resident position is filled with opportunities to work administratively and educationally and even has the potential to drive interinstitutional educational change.1 However, many chief residents feel their administrative roles outweigh their educational ones.2,3 This worried me, as the administrative side of program leadership was something that I had little experience in. Would I be weighed down with answering emails and fielding grievances from other fellows? While I did occasionally have that responsibility, my experiences as a chief fellow meant being intimately involved in one program’s response and growth during a national change to PHM as a field, while also coaching those from other programs on how to respond to these many changes.
The dawn of this new era of PHM saw the first board-certified hospitalists crowned and the first fellowships accredited by the Accreditation Council for Graduate Medical Education within the past academic year. I experienced this in a unique position as a chief fellow – an insider as part of the administration and an outsider as a prospective specialist. Prior to the recent accreditation and certification, PHM fellowship graduates were becoming successful academic physicians. A 2014 study of over 80% of all graduated PHM fellows showed nearly all had academic positions in which they taught students and residents. Many of these graduates also participated in research, with two-thirds being the first author on at least one peer-reviewed article.4
However, we also know that, prior to accreditation, fellowship training was varied, with clinical time ranging from 20% to 65%, in addition to wide variability in billing practices, scholarly practices, and the ability to pursue advanced nonclinical training, such as coursework or master’s degrees in quality improvement or education.5 With PHM fellowships becoming accredited and hospitalists becoming board certified, this is going to change, hopefully for the better.
National accrediting bodies like the ACGME create standards for programs to follow, but as a field we have to make sure we know what those standards mean for our future fellows and our educators. At my own program, these standards meant a significant reduction in clinical time, which was the main way fellows obtained content mastery in PHM. There were also concerns from practicing hospitalists about what it would mean if they did not or could not “grandfather in” to board certification. Would they be pushed out of their jobs or forced into less desirable ones? Would they be able to continue teaching and working with fellows?
As I reflect on experiencing this tumultuous time of change for our specialty, my main takeaway is that board certification of PHM faculty and accreditation of fellowships is an important step to creating the next generation of productive academic hospitalists. The greatest benefit for PHM fellows is that ACGME accreditation mandates that they be treated as learners, and not just junior attendings who are paid less. Many programs rely on fellow billing to fund fellowships, which can create a culture where the focus falls away from exploring a wide variety of educational opportunities and toward an exclusive or near-exclusive service-learning model.
This old model can come at the expense of opportunities such as conferences or secondary degrees. Under ACGME accreditation, fellowships will also be required to provide a regimented system of mentorship and support, more than just nonclinical time, to allow fellows to follow their interests and passions, whether that be in clinical hospital medicine, education, quality, advocacy or more. When these fellows graduate and become board certified, they will truly have recognition as specialists in the field, and be able to advance the field in any setting they choose to practice.
Like any change, this shift in our field also comes with our fair share of risks. Fellowship programs have to be careful about what they take away from an accreditation process that can be incredibly time-consuming and difficult. Leadership at these programs need to look critically at the changes they are required to make, and ensure they are integrated intelligently in a way that benefits the fellows.
At Baylor, while a decrease in clinical time was required, our leadership saw it as an opportunity to implement active learning and assessment techniques to improve clinical mastery with less clinical time. While many programs may need to make significant changes to align with ACGME standards, a key lesson in education is that these changes also need to reflect the goal of the program, to create expert academicians, clinicians, and leaders in PHM.
One of the largest challenges brought about by these changes is how we take into account pediatric hospitalists with clinical expertise who either are not academically oriented or are not eligible for board certification. Excluding them from participating in fellowship training or as productive members of our groups can create a hidden curriculum that board certification and academic practice are the only way forward in our field. We also risk excluding those with the ability to fill the largest need in our specialty, those who practice clinically in the community.6
We must ensure that our desire to have productive academic faculty does not result in the loss of those with clinical expertise, both for the care of our patients and the education of our learners. Whether that solution lies with alternative certification procedures or through thoughtful hiring and educational policies is yet to be seen.
Overall, as PHM’s chief fellow this past academic year, I found that we have a lot to be excited for as our field continues to grow. With this growth, we need be careful about how we move forward with the standardization of our training, education, and faculty practices to align with our core values of excellent care for children and advancement of our field to meet their needs and the needs of our medical system. I am grateful to the many PHM leaders and providers who have thoughtfully stimulated so much growth in the field and paved the way for current and future generations of fellows to benefit from that growth.
Dr. Cohen is an assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine and Texas Children’s Hospital. He graduated from PHM fellowship in June 2020 at Baylor, dedicating himself to developing expertise in medical education. He would like to thank Dr. Michelle Lopez for her assistance in revising this article.
References
1. Myers RE et al. Pediatric chief resident exchange program: A novel method to share educational ideas across training programs. Acad Pediatr. 2019. doi: S1876-2859(19)30386-9.
2. Norris T et al. Do program directors and their chief residents view the role of chief resident similarly? Family Medicine. 1996;28(5):343-5.
3. Dabrow SM et al. Two perspectives on the educational and administrative roles of the pediatric chief resident. J Grad Med Educ. 2011;3(1):17-20.
4. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.
5. Shah NH et al. The current state of pediatric hospital medicine fellowships: A survey of program directors. J Hosp Med. 2016;11(5):324-8.
6. Leyenaar JK et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.
Hospitalist movers and shakers – July 2020
Rupesh Prasad, MD, SFHM, recently started a new role as medical director of care management for Advocate Aurora Health in Milwaukee. His focus areas include clinical documentation and care transition for inpatients. He was previously the quality and utilization officer for Aurora Sinai Medical Center. Dr. Prasad is a hospitalist with 15 years of experience and has served as the chief of staff at Aurora Sinai Medical Center. He is the cochair for the Advocate Aurora Health Inpatient Physician Informatics Committee, where his focus is on optimization of EHR for the end user.
Dr. Prasad cochairs the Society of Hospital Medicine’s IT Special Interest Group and sits on the Hospital Quality and Patient Safety Committee. He is the president of SHM’s Wisconsin Chapter.
David Rice, MD, recently earned promotion to chief medical officer for Baptist Health, a nonprofit health care system based in Jacksonville, Fla. In addition to his role as CMO, Dr. Rice will maintain the titles of senior vice president and chief quality officer.
Dr. Rice, who has spent the past 5 years as chief quality officer at Baptist Health, will oversee clinical quality, patient safety, and performance improvement. The Baptist Health system includes 200 different points of care.
Dr. Rice takes over for Keith Stein, MD, who had served as Baptist’s CMO since 1999.
Alabama hospitalist Jade Brice-Roshell, MD, has been named one of the “70 African American Leaders in Health Care to Know in 2020” list by Becker’s Hospital Review.
Dr. Brice-Roshell has served as Shelby Baptist Medical Center’s (Alabaster, Ala.) CMO for the past year and has been a Shelby staff member since 2015. It is the second year in a row that she has been honored by Becker’s on this list.
After a nationwide search, executive leaders at Bassett Medical Center in Cooperstown, N.Y., have elected to elevate hospitalist Kai Mebust, MD, FHM, to the role of chief of the department of medicine, succeeding Charles Hyman, MD. Dr. Mebust had been working alongside Dr. Hyman as associate chief since March 2019 while the network was seeking a successor. It turns out they had their man in house all along.
Dr. Mebust has 16 years of experience with Bassett, including 10 years as chief of the hospitalist division and 4 years as medical director of the network’s hospitalist program. In his new position, he will be charged with directing care and providing leadership for the system’s physicians.
Prisma Health Tuomey Hospital (Sumter, S.C.) has raised its level of care for children, newborns, and infants by creating a new pediatric hospitalist program through a strengthened relationship with Children’s Hospital-Midlands in Columbia, S.C.
The rural community has been affiliated with Children’s for a long time, but the new setup places full-time physicians in the Sumter facility that are part of the Children’s team. Residents in and around Sumter will no longer need to travel to Columbia to take advantage of the high-level service.
The pediatric hospitalist team will work closely with local pediatricians and family physicians to ensure that follow-ups and other preventative treatments are handled once a child is discharged from Tuomey Hospital.
Rupesh Prasad, MD, SFHM, recently started a new role as medical director of care management for Advocate Aurora Health in Milwaukee. His focus areas include clinical documentation and care transition for inpatients. He was previously the quality and utilization officer for Aurora Sinai Medical Center. Dr. Prasad is a hospitalist with 15 years of experience and has served as the chief of staff at Aurora Sinai Medical Center. He is the cochair for the Advocate Aurora Health Inpatient Physician Informatics Committee, where his focus is on optimization of EHR for the end user.
Dr. Prasad cochairs the Society of Hospital Medicine’s IT Special Interest Group and sits on the Hospital Quality and Patient Safety Committee. He is the president of SHM’s Wisconsin Chapter.
David Rice, MD, recently earned promotion to chief medical officer for Baptist Health, a nonprofit health care system based in Jacksonville, Fla. In addition to his role as CMO, Dr. Rice will maintain the titles of senior vice president and chief quality officer.
Dr. Rice, who has spent the past 5 years as chief quality officer at Baptist Health, will oversee clinical quality, patient safety, and performance improvement. The Baptist Health system includes 200 different points of care.
Dr. Rice takes over for Keith Stein, MD, who had served as Baptist’s CMO since 1999.
Alabama hospitalist Jade Brice-Roshell, MD, has been named one of the “70 African American Leaders in Health Care to Know in 2020” list by Becker’s Hospital Review.
Dr. Brice-Roshell has served as Shelby Baptist Medical Center’s (Alabaster, Ala.) CMO for the past year and has been a Shelby staff member since 2015. It is the second year in a row that she has been honored by Becker’s on this list.
After a nationwide search, executive leaders at Bassett Medical Center in Cooperstown, N.Y., have elected to elevate hospitalist Kai Mebust, MD, FHM, to the role of chief of the department of medicine, succeeding Charles Hyman, MD. Dr. Mebust had been working alongside Dr. Hyman as associate chief since March 2019 while the network was seeking a successor. It turns out they had their man in house all along.
Dr. Mebust has 16 years of experience with Bassett, including 10 years as chief of the hospitalist division and 4 years as medical director of the network’s hospitalist program. In his new position, he will be charged with directing care and providing leadership for the system’s physicians.
Prisma Health Tuomey Hospital (Sumter, S.C.) has raised its level of care for children, newborns, and infants by creating a new pediatric hospitalist program through a strengthened relationship with Children’s Hospital-Midlands in Columbia, S.C.
The rural community has been affiliated with Children’s for a long time, but the new setup places full-time physicians in the Sumter facility that are part of the Children’s team. Residents in and around Sumter will no longer need to travel to Columbia to take advantage of the high-level service.
The pediatric hospitalist team will work closely with local pediatricians and family physicians to ensure that follow-ups and other preventative treatments are handled once a child is discharged from Tuomey Hospital.
Rupesh Prasad, MD, SFHM, recently started a new role as medical director of care management for Advocate Aurora Health in Milwaukee. His focus areas include clinical documentation and care transition for inpatients. He was previously the quality and utilization officer for Aurora Sinai Medical Center. Dr. Prasad is a hospitalist with 15 years of experience and has served as the chief of staff at Aurora Sinai Medical Center. He is the cochair for the Advocate Aurora Health Inpatient Physician Informatics Committee, where his focus is on optimization of EHR for the end user.
Dr. Prasad cochairs the Society of Hospital Medicine’s IT Special Interest Group and sits on the Hospital Quality and Patient Safety Committee. He is the president of SHM’s Wisconsin Chapter.
David Rice, MD, recently earned promotion to chief medical officer for Baptist Health, a nonprofit health care system based in Jacksonville, Fla. In addition to his role as CMO, Dr. Rice will maintain the titles of senior vice president and chief quality officer.
Dr. Rice, who has spent the past 5 years as chief quality officer at Baptist Health, will oversee clinical quality, patient safety, and performance improvement. The Baptist Health system includes 200 different points of care.
Dr. Rice takes over for Keith Stein, MD, who had served as Baptist’s CMO since 1999.
Alabama hospitalist Jade Brice-Roshell, MD, has been named one of the “70 African American Leaders in Health Care to Know in 2020” list by Becker’s Hospital Review.
Dr. Brice-Roshell has served as Shelby Baptist Medical Center’s (Alabaster, Ala.) CMO for the past year and has been a Shelby staff member since 2015. It is the second year in a row that she has been honored by Becker’s on this list.
After a nationwide search, executive leaders at Bassett Medical Center in Cooperstown, N.Y., have elected to elevate hospitalist Kai Mebust, MD, FHM, to the role of chief of the department of medicine, succeeding Charles Hyman, MD. Dr. Mebust had been working alongside Dr. Hyman as associate chief since March 2019 while the network was seeking a successor. It turns out they had their man in house all along.
Dr. Mebust has 16 years of experience with Bassett, including 10 years as chief of the hospitalist division and 4 years as medical director of the network’s hospitalist program. In his new position, he will be charged with directing care and providing leadership for the system’s physicians.
Prisma Health Tuomey Hospital (Sumter, S.C.) has raised its level of care for children, newborns, and infants by creating a new pediatric hospitalist program through a strengthened relationship with Children’s Hospital-Midlands in Columbia, S.C.
The rural community has been affiliated with Children’s for a long time, but the new setup places full-time physicians in the Sumter facility that are part of the Children’s team. Residents in and around Sumter will no longer need to travel to Columbia to take advantage of the high-level service.
The pediatric hospitalist team will work closely with local pediatricians and family physicians to ensure that follow-ups and other preventative treatments are handled once a child is discharged from Tuomey Hospital.
Learn to anticipate, resolve difficult interactions with patients
Every physician encounters difficult or challenging patients during their career, but learning how to anticipate and handle these interactions is not something taught in medical school or residency, according to Donald W. Black, MD, MS.
Difficult or challenging encounters with patients are not only unavoidable, they should be expected, Dr. Black said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
“Every doctor I know has had challenging interactions,” he said. About 15% of encounters were deemed “difficult” in a prospective study of patients by Jeffrey L. Jackson, MD, MPH, and Kurt Kroenke, MD. A depressive or anxiety disorder was present in 29% of patients, with 11% experiencing two or more disorders. Major depression was present in 8.4%, other depressive disorders in 17.4%, panic disorder in 1.4%, and other anxiety disorders in 14.2% of patients. Dr. Jackson and Dr. Kroenke found that difficult patients demonstrated disrespect and anger, made threats, and locked themselves in rooms (Arch Intern Med. 1999 May 24;159[10]:1069-75). “Rest assured, you are not the only psychiatrist to face this type of issue,” Dr. Black said at the meeting, presented by Global Academy for Medical Education.
Common scenarios can include patients who want certain tests performed after researching symptoms online, threats of legal or social media action after feeling like they are not being listened to, a demand for a second opinion after not agreeing with a physician’s diagnosis, mistrust of doctors after presenting with symptoms and not being diagnosed, patients who focus on negative outcomes, and those who do not comply with treatment. These patients can often appear angry, defensive, frightened or resistant, or manipulative; may provide vague or exaggerated symptoms; or may inappropriately rely on hospital or clinic staff for emotional and physical support.
To complicate matters, the patients’ condition also might contribute to difficult interactions, such as in patients who have conditions like chronic pain or fibromyalgia.
“These often contribute because patients never feel that their problems are being appropriately addressed,” said Dr. Black, professor of psychiatry at the University of Iowa in Iowa City. Patients with psychiatric disorders can also present unique challenges that may result in difficult encounters. Patients with anxiety might not be able to be reassured by their doctor, for example, or patients with eating disorders might refuse treatment recommendations, he said.
Difficult encounters can lead to physicians feeling angry, upset, stressed, disrespected, abused, or fearful. But “it’s not just about the patient,” Dr. Black said. Physicians can become angry or defensive because of burnout, stress, or frustration, which can lead to them snapping at patients. Physicians are also overworked, sleep-deprived, and busier than they’d like to be, he added. Personal problems can contribute, and a physician’s belief system can cause a bad interaction with a patient. If physicians “label” one of their patients, that might end up becoming a “self-fulfilling prophecy” for that patient, Dr. Black said. Poor communication, such as not conveying bad news appropriately or with empathy, seeing a patient but never making eye contact, and using medical jargon that could be confusing to the patient, also can contribute to a challenging encounter, he added.
Situational issues also might create a bad experience for the patient. For example, a patient might find it hard to make an appointment, or the clinic might be busy or have a lack of privacy or encounter administrative issues. For patients who do not speak English as their native language, not having access to an interpreter can lead to frustration on the part of both the physician and the patient. “Bad interactions are not good for patient care,” Dr. Black said.
The key to resolving these issues is to focus on the goal, Dr. Black said. “We all want the same thing. We want to help the patient get better; we want to keep patients healthy; we want to keep them happy; we want to be fulfilled; [and] we want to manage our time and make a living – and meet our professional expectations.”
Begin by recognizing the difficult situation and assessing how the patient, the environment, or you might be contributing to the problem. “You have to step back and say what’s going on with this, and what are the factors that are combining to create this situation,” Dr. Black said. It is important to be calm and professional and not argue or talk over the patient. The goal is to work with the patient to find a solution.
One technique is to verbalize the problem without blaming the patient, the physician, or the environment (“We both have very different views about how your symptoms should be investigated, and that’s causing some difficulty between us. Do you agree?”).
There also might be alternative explanations for a patient’s behavior. For example, anger could be misdirected at a physician because of anxiety surrounding an unrelated event. In this case, it is important to listen to the patient and empathize, which will help the patient feel supported and build a rapport that can aid in resolving the problem encounter, Dr. Black said. Finding common ground when patients and physicians have different ideas on treatment or diagnosis is another way to help resolve a difficult encounter.
However, setting boundaries also is important, he noted. If, after remediation or if patients demonstrate signs of threatening or abusive behavior, initiate sexual advances, refuse to follow a treatment plan, fail to pay their bills, or are potentially putting themselves in harm’s way through noncompliance, a physician might consider terminating the relationship. Terminating the patient relationship should be done after attempting to work with the patient through a case manager and team members, and clearly advising a patient about behavior that could lead to termination of the patient-provider relationship.
Global Academy and this news organization are owned by the same parent company. Dr. Black reported that he is a consultant for Otsuka and receives royalties from American Psychiatric Publishing, Oxford University Press, and UpToDate. In addition, he receives funding from Nellie Ball Trust, the National Institute on Drug Abuse, the National Institute on Aging, and the National Center for Responsible Gaming.
Every physician encounters difficult or challenging patients during their career, but learning how to anticipate and handle these interactions is not something taught in medical school or residency, according to Donald W. Black, MD, MS.
Difficult or challenging encounters with patients are not only unavoidable, they should be expected, Dr. Black said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
“Every doctor I know has had challenging interactions,” he said. About 15% of encounters were deemed “difficult” in a prospective study of patients by Jeffrey L. Jackson, MD, MPH, and Kurt Kroenke, MD. A depressive or anxiety disorder was present in 29% of patients, with 11% experiencing two or more disorders. Major depression was present in 8.4%, other depressive disorders in 17.4%, panic disorder in 1.4%, and other anxiety disorders in 14.2% of patients. Dr. Jackson and Dr. Kroenke found that difficult patients demonstrated disrespect and anger, made threats, and locked themselves in rooms (Arch Intern Med. 1999 May 24;159[10]:1069-75). “Rest assured, you are not the only psychiatrist to face this type of issue,” Dr. Black said at the meeting, presented by Global Academy for Medical Education.
Common scenarios can include patients who want certain tests performed after researching symptoms online, threats of legal or social media action after feeling like they are not being listened to, a demand for a second opinion after not agreeing with a physician’s diagnosis, mistrust of doctors after presenting with symptoms and not being diagnosed, patients who focus on negative outcomes, and those who do not comply with treatment. These patients can often appear angry, defensive, frightened or resistant, or manipulative; may provide vague or exaggerated symptoms; or may inappropriately rely on hospital or clinic staff for emotional and physical support.
To complicate matters, the patients’ condition also might contribute to difficult interactions, such as in patients who have conditions like chronic pain or fibromyalgia.
“These often contribute because patients never feel that their problems are being appropriately addressed,” said Dr. Black, professor of psychiatry at the University of Iowa in Iowa City. Patients with psychiatric disorders can also present unique challenges that may result in difficult encounters. Patients with anxiety might not be able to be reassured by their doctor, for example, or patients with eating disorders might refuse treatment recommendations, he said.
Difficult encounters can lead to physicians feeling angry, upset, stressed, disrespected, abused, or fearful. But “it’s not just about the patient,” Dr. Black said. Physicians can become angry or defensive because of burnout, stress, or frustration, which can lead to them snapping at patients. Physicians are also overworked, sleep-deprived, and busier than they’d like to be, he added. Personal problems can contribute, and a physician’s belief system can cause a bad interaction with a patient. If physicians “label” one of their patients, that might end up becoming a “self-fulfilling prophecy” for that patient, Dr. Black said. Poor communication, such as not conveying bad news appropriately or with empathy, seeing a patient but never making eye contact, and using medical jargon that could be confusing to the patient, also can contribute to a challenging encounter, he added.
Situational issues also might create a bad experience for the patient. For example, a patient might find it hard to make an appointment, or the clinic might be busy or have a lack of privacy or encounter administrative issues. For patients who do not speak English as their native language, not having access to an interpreter can lead to frustration on the part of both the physician and the patient. “Bad interactions are not good for patient care,” Dr. Black said.
The key to resolving these issues is to focus on the goal, Dr. Black said. “We all want the same thing. We want to help the patient get better; we want to keep patients healthy; we want to keep them happy; we want to be fulfilled; [and] we want to manage our time and make a living – and meet our professional expectations.”
Begin by recognizing the difficult situation and assessing how the patient, the environment, or you might be contributing to the problem. “You have to step back and say what’s going on with this, and what are the factors that are combining to create this situation,” Dr. Black said. It is important to be calm and professional and not argue or talk over the patient. The goal is to work with the patient to find a solution.
One technique is to verbalize the problem without blaming the patient, the physician, or the environment (“We both have very different views about how your symptoms should be investigated, and that’s causing some difficulty between us. Do you agree?”).
There also might be alternative explanations for a patient’s behavior. For example, anger could be misdirected at a physician because of anxiety surrounding an unrelated event. In this case, it is important to listen to the patient and empathize, which will help the patient feel supported and build a rapport that can aid in resolving the problem encounter, Dr. Black said. Finding common ground when patients and physicians have different ideas on treatment or diagnosis is another way to help resolve a difficult encounter.
However, setting boundaries also is important, he noted. If, after remediation or if patients demonstrate signs of threatening or abusive behavior, initiate sexual advances, refuse to follow a treatment plan, fail to pay their bills, or are potentially putting themselves in harm’s way through noncompliance, a physician might consider terminating the relationship. Terminating the patient relationship should be done after attempting to work with the patient through a case manager and team members, and clearly advising a patient about behavior that could lead to termination of the patient-provider relationship.
Global Academy and this news organization are owned by the same parent company. Dr. Black reported that he is a consultant for Otsuka and receives royalties from American Psychiatric Publishing, Oxford University Press, and UpToDate. In addition, he receives funding from Nellie Ball Trust, the National Institute on Drug Abuse, the National Institute on Aging, and the National Center for Responsible Gaming.
Every physician encounters difficult or challenging patients during their career, but learning how to anticipate and handle these interactions is not something taught in medical school or residency, according to Donald W. Black, MD, MS.
Difficult or challenging encounters with patients are not only unavoidable, they should be expected, Dr. Black said in a virtual meeting presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.
“Every doctor I know has had challenging interactions,” he said. About 15% of encounters were deemed “difficult” in a prospective study of patients by Jeffrey L. Jackson, MD, MPH, and Kurt Kroenke, MD. A depressive or anxiety disorder was present in 29% of patients, with 11% experiencing two or more disorders. Major depression was present in 8.4%, other depressive disorders in 17.4%, panic disorder in 1.4%, and other anxiety disorders in 14.2% of patients. Dr. Jackson and Dr. Kroenke found that difficult patients demonstrated disrespect and anger, made threats, and locked themselves in rooms (Arch Intern Med. 1999 May 24;159[10]:1069-75). “Rest assured, you are not the only psychiatrist to face this type of issue,” Dr. Black said at the meeting, presented by Global Academy for Medical Education.
Common scenarios can include patients who want certain tests performed after researching symptoms online, threats of legal or social media action after feeling like they are not being listened to, a demand for a second opinion after not agreeing with a physician’s diagnosis, mistrust of doctors after presenting with symptoms and not being diagnosed, patients who focus on negative outcomes, and those who do not comply with treatment. These patients can often appear angry, defensive, frightened or resistant, or manipulative; may provide vague or exaggerated symptoms; or may inappropriately rely on hospital or clinic staff for emotional and physical support.
To complicate matters, the patients’ condition also might contribute to difficult interactions, such as in patients who have conditions like chronic pain or fibromyalgia.
“These often contribute because patients never feel that their problems are being appropriately addressed,” said Dr. Black, professor of psychiatry at the University of Iowa in Iowa City. Patients with psychiatric disorders can also present unique challenges that may result in difficult encounters. Patients with anxiety might not be able to be reassured by their doctor, for example, or patients with eating disorders might refuse treatment recommendations, he said.
Difficult encounters can lead to physicians feeling angry, upset, stressed, disrespected, abused, or fearful. But “it’s not just about the patient,” Dr. Black said. Physicians can become angry or defensive because of burnout, stress, or frustration, which can lead to them snapping at patients. Physicians are also overworked, sleep-deprived, and busier than they’d like to be, he added. Personal problems can contribute, and a physician’s belief system can cause a bad interaction with a patient. If physicians “label” one of their patients, that might end up becoming a “self-fulfilling prophecy” for that patient, Dr. Black said. Poor communication, such as not conveying bad news appropriately or with empathy, seeing a patient but never making eye contact, and using medical jargon that could be confusing to the patient, also can contribute to a challenging encounter, he added.
Situational issues also might create a bad experience for the patient. For example, a patient might find it hard to make an appointment, or the clinic might be busy or have a lack of privacy or encounter administrative issues. For patients who do not speak English as their native language, not having access to an interpreter can lead to frustration on the part of both the physician and the patient. “Bad interactions are not good for patient care,” Dr. Black said.
The key to resolving these issues is to focus on the goal, Dr. Black said. “We all want the same thing. We want to help the patient get better; we want to keep patients healthy; we want to keep them happy; we want to be fulfilled; [and] we want to manage our time and make a living – and meet our professional expectations.”
Begin by recognizing the difficult situation and assessing how the patient, the environment, or you might be contributing to the problem. “You have to step back and say what’s going on with this, and what are the factors that are combining to create this situation,” Dr. Black said. It is important to be calm and professional and not argue or talk over the patient. The goal is to work with the patient to find a solution.
One technique is to verbalize the problem without blaming the patient, the physician, or the environment (“We both have very different views about how your symptoms should be investigated, and that’s causing some difficulty between us. Do you agree?”).
There also might be alternative explanations for a patient’s behavior. For example, anger could be misdirected at a physician because of anxiety surrounding an unrelated event. In this case, it is important to listen to the patient and empathize, which will help the patient feel supported and build a rapport that can aid in resolving the problem encounter, Dr. Black said. Finding common ground when patients and physicians have different ideas on treatment or diagnosis is another way to help resolve a difficult encounter.
However, setting boundaries also is important, he noted. If, after remediation or if patients demonstrate signs of threatening or abusive behavior, initiate sexual advances, refuse to follow a treatment plan, fail to pay their bills, or are potentially putting themselves in harm’s way through noncompliance, a physician might consider terminating the relationship. Terminating the patient relationship should be done after attempting to work with the patient through a case manager and team members, and clearly advising a patient about behavior that could lead to termination of the patient-provider relationship.
Global Academy and this news organization are owned by the same parent company. Dr. Black reported that he is a consultant for Otsuka and receives royalties from American Psychiatric Publishing, Oxford University Press, and UpToDate. In addition, he receives funding from Nellie Ball Trust, the National Institute on Drug Abuse, the National Institute on Aging, and the National Center for Responsible Gaming.
FROM CP/AACP PSYCHIATRY UPDATE
Residents, fellows will get minimum 6 weeks leave for caregiving
the American Board of Medical Specialties has announced.
The “ABMS Policy on Parental, Caregiver and Family Leave” announced July 13 was developed after a report from the Accreditation Council for Graduate Medical Education’s Council of Review Committee Residents in June 2019.
Richard E. Hawkins, MD, ABMS President and CEO, said in a statement that “the growing shifts in viewpoints regarding work-life balance and parental roles had a great influence in the creation of this policy, which fosters an environment that supports our trainees’ ability to care not only for patients, but also for themselves and their families.”
Specifically, the time can be taken for birth and care of a newborn, adopting a child, or becoming a foster parent; care of a child, spouse, or parent with a serious health condition; or the trainee’s own serious health condition. The policy applies to member boards with training programs of at least 2 years.
Boards must communicate when a leave will require an official extension to avoid disruptions to a physician’s career trajectory, a delay in starting a fellowship, or moving into a salaried position.
Work/life balance was by far the biggest challenge reported in the Medscape Residents Lifestyle & Happiness Report 2019.
Several member boards had already implemented policies that offered more flexibility without unduly delaying board certification; now ABMS is extending that to all boards.
ABMS says member boards may limit the maximum time away in a single year or level of training and directed member boards to “make reasonable testing accommodations” – for example, by allowing candidates to take an exam provided the candidate completes all training requirements by a certain date.
Kristy Rialon, MD, an author of the ACGME report and assistant professor of surgery at Baylor College of Medicine and the Texas Children’s Hospital, both in Houston, noted the significance of the change in a news release.
“By virtue of their ages, residents and fellows – male and female – often find themselves having and raising children, as well as serving as family members’ caregivers,” Dr. Rialon said. “By adopting more realistic and compassionate approaches, the ABMS member boards will significantly improve the quality of life for residents and fellows. This also will support our female physicians, helping to narrow the gender gap in their career advancement by allowing for greater leave flexibility.”
A Medscape survey published July 15 said work-life balance was the No. 1 concern of female physicians, far outpacing pay.
A version of this article originally appeared on Medscape.com.
the American Board of Medical Specialties has announced.
The “ABMS Policy on Parental, Caregiver and Family Leave” announced July 13 was developed after a report from the Accreditation Council for Graduate Medical Education’s Council of Review Committee Residents in June 2019.
Richard E. Hawkins, MD, ABMS President and CEO, said in a statement that “the growing shifts in viewpoints regarding work-life balance and parental roles had a great influence in the creation of this policy, which fosters an environment that supports our trainees’ ability to care not only for patients, but also for themselves and their families.”
Specifically, the time can be taken for birth and care of a newborn, adopting a child, or becoming a foster parent; care of a child, spouse, or parent with a serious health condition; or the trainee’s own serious health condition. The policy applies to member boards with training programs of at least 2 years.
Boards must communicate when a leave will require an official extension to avoid disruptions to a physician’s career trajectory, a delay in starting a fellowship, or moving into a salaried position.
Work/life balance was by far the biggest challenge reported in the Medscape Residents Lifestyle & Happiness Report 2019.
Several member boards had already implemented policies that offered more flexibility without unduly delaying board certification; now ABMS is extending that to all boards.
ABMS says member boards may limit the maximum time away in a single year or level of training and directed member boards to “make reasonable testing accommodations” – for example, by allowing candidates to take an exam provided the candidate completes all training requirements by a certain date.
Kristy Rialon, MD, an author of the ACGME report and assistant professor of surgery at Baylor College of Medicine and the Texas Children’s Hospital, both in Houston, noted the significance of the change in a news release.
“By virtue of their ages, residents and fellows – male and female – often find themselves having and raising children, as well as serving as family members’ caregivers,” Dr. Rialon said. “By adopting more realistic and compassionate approaches, the ABMS member boards will significantly improve the quality of life for residents and fellows. This also will support our female physicians, helping to narrow the gender gap in their career advancement by allowing for greater leave flexibility.”
A Medscape survey published July 15 said work-life balance was the No. 1 concern of female physicians, far outpacing pay.
A version of this article originally appeared on Medscape.com.
the American Board of Medical Specialties has announced.
The “ABMS Policy on Parental, Caregiver and Family Leave” announced July 13 was developed after a report from the Accreditation Council for Graduate Medical Education’s Council of Review Committee Residents in June 2019.
Richard E. Hawkins, MD, ABMS President and CEO, said in a statement that “the growing shifts in viewpoints regarding work-life balance and parental roles had a great influence in the creation of this policy, which fosters an environment that supports our trainees’ ability to care not only for patients, but also for themselves and their families.”
Specifically, the time can be taken for birth and care of a newborn, adopting a child, or becoming a foster parent; care of a child, spouse, or parent with a serious health condition; or the trainee’s own serious health condition. The policy applies to member boards with training programs of at least 2 years.
Boards must communicate when a leave will require an official extension to avoid disruptions to a physician’s career trajectory, a delay in starting a fellowship, or moving into a salaried position.
Work/life balance was by far the biggest challenge reported in the Medscape Residents Lifestyle & Happiness Report 2019.
Several member boards had already implemented policies that offered more flexibility without unduly delaying board certification; now ABMS is extending that to all boards.
ABMS says member boards may limit the maximum time away in a single year or level of training and directed member boards to “make reasonable testing accommodations” – for example, by allowing candidates to take an exam provided the candidate completes all training requirements by a certain date.
Kristy Rialon, MD, an author of the ACGME report and assistant professor of surgery at Baylor College of Medicine and the Texas Children’s Hospital, both in Houston, noted the significance of the change in a news release.
“By virtue of their ages, residents and fellows – male and female – often find themselves having and raising children, as well as serving as family members’ caregivers,” Dr. Rialon said. “By adopting more realistic and compassionate approaches, the ABMS member boards will significantly improve the quality of life for residents and fellows. This also will support our female physicians, helping to narrow the gender gap in their career advancement by allowing for greater leave flexibility.”
A Medscape survey published July 15 said work-life balance was the No. 1 concern of female physicians, far outpacing pay.
A version of this article originally appeared on Medscape.com.
PHM fellowship changes in response to the COVID-19 pandemic
The COVID-19 surge and pandemic have changed many things in medicine, from how we round on the wards to our increased use of telemedicine in outpatient and inpatient care. This not only changed our interactions with patients, but it also changed our learners’ education. From March to May 2020 during the COVID-19 pandemic, many Pediatric Hospital Medicine (PHM) fellowship directors were required to adjust clinical responsibilities and scholarly activities. These changes led to unique challenges and learning opportunities for fellows and faculty.
Many fellowships were asked to make changes to patient care for patient/provider safety. Because of low censuses, the University of Pittsburgh Medical Center’s Pittsburgh Children’s Hospital closed their observation unit; as a result, Elise Lu, MD, PhD, PHM fellow, spent time rounding on inpatient units instead of the observation unit. At the Children’s Hospital of Los Angeles, PHM fellow Brandon Palmer, MD, said his in-person child abuse elective was switched to a virtual elective. Dr. Adam Cohen, chief PHM fellow at Baylor College of Medicine/Texas Children’s Hospital, both in Houston, offered to care for adult patients and provide telehealth services to pediatric patients, but was never called to participate.
At other programs, fellows experienced greater changes to patient care and systems-based practice. Carlos Plancarte, MD, PHM fellow at Children’s Hospital of Montefiore, New York, provided care for patients up to the age of 30 years as his training hospital began admitting adult patients. Jeremiah Cleveland, MD, PHM fellowship director at Maimonides Children’s Hospital, New York, shared that his fellow’s “away elective” at a pediatric long-term acute care facility was canceled. Dr. Cleveland changed the fellow’s rotation to an infectious disease rotation, which gave her a unique opportunity to evaluate the clinical and nonclinical aspects of pandemic and disaster response.
PHM fellows also experienced changes to their scholarly activities. Matthew Shapiro, MD, a fellow at Anne and Robert H. Lurie Children’s Hospital in Chicago, had to place his quality improvement research on hold and is writing a commentary with his mentors. Marie Pfarr, MD, a fellow at Cincinnati Children’s Hospital and Medical Center, changed her plans from a simulation-based research project to studying compassion fatigue. Many fellows had workshops, platform and/or poster presentations at the Pediatric Academic Societies Meeting and/or the Pediatric Hospital Medicine Conference, both of which were canceled.
Some fellows felt the pandemic provided them an opportunity to learn communication and interpersonal skills. Dr. Shapiro observed his mentors effectively communicating while managing a crisis. Dr. Plancarte shared that he learned that saying “I don’t know” can be helpful when effectively leading a team.
Despite the changes, the COVID-19 pandemic’s most important lesson was the creation of a supportive community. Across the country, PHM fellows were supported by faculty, and faculty by their fellows. Dr. Plancarte observed how his colleagues united during a challenging situation to support each other. Ritu Patel, MD, PHM fellowship director at Kaiser Oakland shared that her fellowship’s weekly informal meetings helped bring her fellowship’s fellows and faculty closer. Joel Forman, MD, PHM fellowship director and vice chair of education at Mount Sinai Kravis Children’s Hospital in New York stressed the importance of camaraderie amongst faculty and learners.
While the pandemic continues, and long after it has passed, fellowship programs have learned that fostering community across training lines is important for both fellows and faculty.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s. She is a clinical assistant professor of pediatrics at Case Western Reserve University, Cleveland, and serves as the pediatrics editor for the Hospitalist.
The COVID-19 surge and pandemic have changed many things in medicine, from how we round on the wards to our increased use of telemedicine in outpatient and inpatient care. This not only changed our interactions with patients, but it also changed our learners’ education. From March to May 2020 during the COVID-19 pandemic, many Pediatric Hospital Medicine (PHM) fellowship directors were required to adjust clinical responsibilities and scholarly activities. These changes led to unique challenges and learning opportunities for fellows and faculty.
Many fellowships were asked to make changes to patient care for patient/provider safety. Because of low censuses, the University of Pittsburgh Medical Center’s Pittsburgh Children’s Hospital closed their observation unit; as a result, Elise Lu, MD, PhD, PHM fellow, spent time rounding on inpatient units instead of the observation unit. At the Children’s Hospital of Los Angeles, PHM fellow Brandon Palmer, MD, said his in-person child abuse elective was switched to a virtual elective. Dr. Adam Cohen, chief PHM fellow at Baylor College of Medicine/Texas Children’s Hospital, both in Houston, offered to care for adult patients and provide telehealth services to pediatric patients, but was never called to participate.
At other programs, fellows experienced greater changes to patient care and systems-based practice. Carlos Plancarte, MD, PHM fellow at Children’s Hospital of Montefiore, New York, provided care for patients up to the age of 30 years as his training hospital began admitting adult patients. Jeremiah Cleveland, MD, PHM fellowship director at Maimonides Children’s Hospital, New York, shared that his fellow’s “away elective” at a pediatric long-term acute care facility was canceled. Dr. Cleveland changed the fellow’s rotation to an infectious disease rotation, which gave her a unique opportunity to evaluate the clinical and nonclinical aspects of pandemic and disaster response.
PHM fellows also experienced changes to their scholarly activities. Matthew Shapiro, MD, a fellow at Anne and Robert H. Lurie Children’s Hospital in Chicago, had to place his quality improvement research on hold and is writing a commentary with his mentors. Marie Pfarr, MD, a fellow at Cincinnati Children’s Hospital and Medical Center, changed her plans from a simulation-based research project to studying compassion fatigue. Many fellows had workshops, platform and/or poster presentations at the Pediatric Academic Societies Meeting and/or the Pediatric Hospital Medicine Conference, both of which were canceled.
Some fellows felt the pandemic provided them an opportunity to learn communication and interpersonal skills. Dr. Shapiro observed his mentors effectively communicating while managing a crisis. Dr. Plancarte shared that he learned that saying “I don’t know” can be helpful when effectively leading a team.
Despite the changes, the COVID-19 pandemic’s most important lesson was the creation of a supportive community. Across the country, PHM fellows were supported by faculty, and faculty by their fellows. Dr. Plancarte observed how his colleagues united during a challenging situation to support each other. Ritu Patel, MD, PHM fellowship director at Kaiser Oakland shared that her fellowship’s weekly informal meetings helped bring her fellowship’s fellows and faculty closer. Joel Forman, MD, PHM fellowship director and vice chair of education at Mount Sinai Kravis Children’s Hospital in New York stressed the importance of camaraderie amongst faculty and learners.
While the pandemic continues, and long after it has passed, fellowship programs have learned that fostering community across training lines is important for both fellows and faculty.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s. She is a clinical assistant professor of pediatrics at Case Western Reserve University, Cleveland, and serves as the pediatrics editor for the Hospitalist.
The COVID-19 surge and pandemic have changed many things in medicine, from how we round on the wards to our increased use of telemedicine in outpatient and inpatient care. This not only changed our interactions with patients, but it also changed our learners’ education. From March to May 2020 during the COVID-19 pandemic, many Pediatric Hospital Medicine (PHM) fellowship directors were required to adjust clinical responsibilities and scholarly activities. These changes led to unique challenges and learning opportunities for fellows and faculty.
Many fellowships were asked to make changes to patient care for patient/provider safety. Because of low censuses, the University of Pittsburgh Medical Center’s Pittsburgh Children’s Hospital closed their observation unit; as a result, Elise Lu, MD, PhD, PHM fellow, spent time rounding on inpatient units instead of the observation unit. At the Children’s Hospital of Los Angeles, PHM fellow Brandon Palmer, MD, said his in-person child abuse elective was switched to a virtual elective. Dr. Adam Cohen, chief PHM fellow at Baylor College of Medicine/Texas Children’s Hospital, both in Houston, offered to care for adult patients and provide telehealth services to pediatric patients, but was never called to participate.
At other programs, fellows experienced greater changes to patient care and systems-based practice. Carlos Plancarte, MD, PHM fellow at Children’s Hospital of Montefiore, New York, provided care for patients up to the age of 30 years as his training hospital began admitting adult patients. Jeremiah Cleveland, MD, PHM fellowship director at Maimonides Children’s Hospital, New York, shared that his fellow’s “away elective” at a pediatric long-term acute care facility was canceled. Dr. Cleveland changed the fellow’s rotation to an infectious disease rotation, which gave her a unique opportunity to evaluate the clinical and nonclinical aspects of pandemic and disaster response.
PHM fellows also experienced changes to their scholarly activities. Matthew Shapiro, MD, a fellow at Anne and Robert H. Lurie Children’s Hospital in Chicago, had to place his quality improvement research on hold and is writing a commentary with his mentors. Marie Pfarr, MD, a fellow at Cincinnati Children’s Hospital and Medical Center, changed her plans from a simulation-based research project to studying compassion fatigue. Many fellows had workshops, platform and/or poster presentations at the Pediatric Academic Societies Meeting and/or the Pediatric Hospital Medicine Conference, both of which were canceled.
Some fellows felt the pandemic provided them an opportunity to learn communication and interpersonal skills. Dr. Shapiro observed his mentors effectively communicating while managing a crisis. Dr. Plancarte shared that he learned that saying “I don’t know” can be helpful when effectively leading a team.
Despite the changes, the COVID-19 pandemic’s most important lesson was the creation of a supportive community. Across the country, PHM fellows were supported by faculty, and faculty by their fellows. Dr. Plancarte observed how his colleagues united during a challenging situation to support each other. Ritu Patel, MD, PHM fellowship director at Kaiser Oakland shared that her fellowship’s weekly informal meetings helped bring her fellowship’s fellows and faculty closer. Joel Forman, MD, PHM fellowship director and vice chair of education at Mount Sinai Kravis Children’s Hospital in New York stressed the importance of camaraderie amongst faculty and learners.
While the pandemic continues, and long after it has passed, fellowship programs have learned that fostering community across training lines is important for both fellows and faculty.
Dr. Kumar is a pediatric hospitalist at Cleveland Clinic Children’s. She is a clinical assistant professor of pediatrics at Case Western Reserve University, Cleveland, and serves as the pediatrics editor for the Hospitalist.