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I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.

Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.

Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:

They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.

They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.

They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.

They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.

They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.

They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.

In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.

Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.

Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:

They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.

They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.

They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.

They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.

They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.

They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.

In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

I have learned a lot about crisis management and leadership in the rapidly changing COVID health care environment. I have learned how to make quick and imperfect decisions with limited information, and how to move on swiftly. I have learned how to quickly fade out memories of how we used to run our business, and pivot to unknown and untested delivery modalities. I have learned how to take regulatory standards as guidance, not doctrine. And I have learned how tell longstanding loyal colleagues that they are being laid off.

Many of these leadership challenges are not new, but the rapidity of change and the weight and magnitude of decision making is unparalleled in my relatively short career. In some ways, it reminds me of some solid lessons I have learned over time as a lifetime runner, with many analogies and applications to leadership.

Some people ask me why I run. “You must get a runner’s high.” The truth is, I have never had a runner’s high. I feel every step. In fact, the very nature of running makes a person feel like they are being pulled under water. Runners are typically tachycardic and short of breath the whole time they are running. But what running does allow for is to ignore some of the signals your body is sending, and wholly and completely focus on other things. I often have my most creative and innovative thoughts while running. So that is why I run. But back to the point of what running and leadership have in common – and how lessons learned can translate between the two:

They are both really hard. As I mentioned above, running literally makes you feel like you are drowning. But when you finish running, it is amazing how easy everything else feels! Similar to leadership, it should feel hard, but not too hard. I have seen firsthand the effects of under- and over-delegating, and both are dysfunctional. Good leadership is a blend of being humble and servant, but also ensuring self-care and endurance. It is also important to acknowledge the difficulty of leadership. Dr. Tom Lee, currently chief medical officer at Press Ganey, is a leader I have always admired. He once said, “Leadership can be very lonely.” At the time, I did not quite understand that, but I have come to experience that feeling occasionally. The other aspect of leadership that I find really hard is that often, people’s anger is misdirected at leaders as a natural outlet for that anger. Part of being a leader is enduring such anger, gaining an understanding for it, and doing what you can to help people through it.

They both work better when you are restored. It sounds generic and cliché, but you can’t be a good runner or a good leader when you are totally depleted.

They both require efficiency. When I was running my first marathon, a complete stranger ran up beside me and started giving me advice. I thought it was sort of strange advice at the time, but it turned out to be sound and useful. He noticed my running pattern of “sticking to the road,” and he told me I should rather “run as the crow flies.” What he meant was to run in as straight of a line as possible, regardless of the road, to preserve energy and save steps. He recommended picking a point on the horizon and running toward that point as straight as possible. As he sped off ahead of me in the next mile, his parting words were, “You’ll thank me at mile 24…” To this day, I still use that tactic, which I find very steadying and calming during running. The same can be said for leadership; as you pick a point on the horizon, keep yourself and your team heading toward that point with intense focus, and before you realize it, you’ve reached your destination.

They both require having a goal. That same stranger who gave me advice on running efficiently also asked what my goal was. It caught me off guard a bit, as I realized my only goal was to finish. He encouraged me to make a goal for the run, which could serve as a motivator when the going got tough. This was another piece of lasting advice I have used for both running and for leadership.

They both can be endured by committing to continuous forward motion. Running and leadership both become psychologically much easier when you realize all you really have to do is maintain continuous forward motion. Some days require less effort than others, but I can always convince myself I am capable of some forward motion.

They both are easier if you don’t overthink things. When I first started in a leadership position, I would have moments of anxiety if I thought too hard about what I was responsible for. Similar to running, it works best if you don’t overthink what difficulties it may bring; rather, just put on your shoes and get going.

In the end, leading during COVID is like stepping onto a new trail. Despite the new terrain and foreign path, my prior training and trusty pair of sneakers – like my leadership skills and past experiences – will get me through this journey, one step at a time.

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is president of SHM.

The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children^1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.³ We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.

STUDY 1

Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.

Background

Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
 

Study overview and results

The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV₁. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
 

Limitations

Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV₁, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
 

Important findings and implications

While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
 

STUDY 2

Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.

Background

Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
 

Study overview and results

The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.⁴ They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
 

Limitations

These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
 

Important findings and implications

This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.

STUDY 3

Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.

Background

Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
 

Study overview and results

The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
 

Limitations

Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
 

Important findings and implications

Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
 

STUDY 4

Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.

Background

Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
 

Study overview and results

The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
 

Limitations

The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
 

Important findings and implications

Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
 

STUDY 5

McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.

Background

Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.

Study overview and results

In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
 

Limitations

This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
 

Important findings and implications

An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
 

Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.

References

1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.

2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.

3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.

4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.

The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children^1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.³ We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.

STUDY 1

Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.

Background

Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
 

Study overview and results

The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV₁. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
 

Limitations

Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV₁, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
 

Important findings and implications

While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
 

STUDY 2

Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.

Background

Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
 

Study overview and results

The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.⁴ They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
 

Limitations

These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
 

Important findings and implications

This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.

STUDY 3

Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.

Background

Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
 

Study overview and results

The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
 

Limitations

Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
 

Important findings and implications

Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
 

STUDY 4

Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.

Background

Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
 

Study overview and results

The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
 

Limitations

The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
 

Important findings and implications

Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
 

STUDY 5

McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.

Background

Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.

Study overview and results

In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
 

Limitations

This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
 

Important findings and implications

An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
 

Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.

References

1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.

2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.

3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.

4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.

The expansion of the field of pediatric hospital medicine in the past 30 years has resulted in improved health care outcomes for hospitalized children^1,2 and has been accompanied by a robust increase in the amount of scholarly work related to the field.³ We performed a review of the literature published in 2019 to identify the 10 articles that had the most impact on pediatric hospital medicine, and presented the findings at HM20 Virtual, the 2020 annual conference of the Society of Hospital Medicine. Five of the selected articles are highlighted here.

STUDY 1

Wechsler ME et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med. 2019 Sep 26;381(13):1227-39.

Background

Current pediatric asthma guidelines suggest adding a long-acting beta-agonist (LABA) to inhaled corticosteroid (ICS) therapy, rather than increasing the ICS dose, for children with poorly controlled asthma. However, these data are based on trials with disproportionately few Black subjects. This study aimed to determine the best step-up therapy for Black patients whose asthma was poorly controlled on ICS monotherapy.
 

Study overview and results

The authors reported two parallel double-blind, randomized, controlled trials, one in children and one in adolescents and adults. The study of children included 280 subjects ranging in age from 5 to 11, with at least one Black grandparent, and with poorly controlled asthma on low-dose ICS therapy. It used a four-way crossover design in which each subject was treated with four different 14-week treatment regimens: either double (medium-dose) or quintuple (high-dose) their baseline ICS dose, with or without the addition of a LABA. A superior response was defined by the composite outcome of at least one fewer asthma exacerbation, more asthma-control days, or a 5–percentage point difference in predicted FEV₁. Forty-six percent of children had improved asthma outcomes when the ICS dose was increased rather than with the addition of a LABA. In contrast, Black adolescents and Black adults had superior responses to the addition of a LABA. There was no significant interaction between the percentage of African ancestry as determined by DNA genotyping and the primary composite outcome. High-dose ICS was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years.
 

Limitations

Approximately 25% of children dropped out of the study, with disproportionately more children dropping out while on a high-dose ICS regimen. Additionally, the difference in the composite outcome was primarily driven by differences in FEV₁, with few subjects demonstrating a difference in asthma exacerbations or asthma-control days. Although a decrease in urinary cortisol to creatinine ratio was noted in children under 8 on high-dose ICS, the study period was not long enough to determine the clinical implications of this finding.
 

Important findings and implications

While studies with a majority of white children have suggested a superior response from adding a LABA compared to increasing the dose of an ICS, almost half of Black children showed a superior response when the dose of an ICS was increased rather than adding a LABA. It is important to note that current guidelines are based on studies with a disproportionate majority of white subjects and may not accurately reflect optimal care for patients in other racial groups. This study underscores the need to include a diverse patient population in research studies.
 

STUDY 2

Chang PW, Newman TB. A simpler prediction rule for rebound hyperbilirubinemia. Pediatrics. 2019 Jul;144(1):e20183712.

Background

Hyperbilirubinemia (jaundice) is estimated to affect 50%-60% of all newborns. Rebound hyperbilirubinemia – a rise in bilirubin after cessation of phototherapy – is common and can lead to recently discharged infants being readmitted for additional therapy. Lack of clear guidelines regarding when to discharge infants with hyperbilirubinemia has likely contributed to practice variation and some trepidation regarding whether a bilirubin level is “low enough” to discontinue therapy.
 

Study overview and results

The authors had previously proposed a three-factor hyperbilirubinemia risk model and sought to simplify their rule further.⁴ They examined a retrospective cohort of 7,048 infants greater than or equal to 35 weeks’ gestation using a random split sample. The authors derived a two-factor model using the same methods and compared its performance to the three-factor model. The two-factor formula was shown to be a good fit as a logistic regression model (Hosmer-Lemeshow test 9.21; P = .33), and the AUROC (area under the receiver operating characteristic) curves for the derivation and validation cohorts were similar between the two-factor (0.877 and 0.876, respectively) and three-factor risk models (0.887 and 0.881, respectively).
 

Limitations

These data are limited to infants receiving their first treatment of phototherapy and have not been externally validated. An important variable, serum bilirubin at phototherapy termination, was estimated in most subjects, which may have affected the accuracy of the prediction rule. Whether infants received home phototherapy was based only on equipment orders, and some infants may have received phototherapy unbeknownst to investigators. Last, infants with rebound hyperbilirubinemia at less than 72 hours after phototherapy discontinuation may have been missed.
 

Important findings and implications

This prediction model provides evidence-based, concrete data that can be used in making joint decisions with families regarding discharge timing of infants with hyperbilirubinemia. It also could be beneficial when deciding appropriate follow-up time after discharge.

STUDY 3

Ramgopal S et al. Risk of serious bacterial infection in infants aged ≤60 days presenting to emergency departments with a history of fever only. J Pediatr. 2019 Jan;204:191-195. doi: 10.1016/j.jpeds.2018.08.043.

Background

Febrile infants aged 60 days and younger are at risk for serious bacterial infections (SBI) including urinary tract infections (UTI), bacteremia, and meningitis. As physical exam is a poor discriminator of SBI in this age group, providers frequently rely on laboratory values and risk factors to guide management. Infants presenting with documented fevers by caregivers but found to have no fever in the emergency department are a challenge, and there are limited data regarding SBI frequency in this population.
 

Study overview and results

The authors performed a secondary analysis of a prospectively gathered cohort of infants aged 60 days and younger within the Pediatric Emergency Care Applied Research Network (PECARN) who had blood, urine, and CSF data available. Notable exclusions included infants who were premature, had a focal infection, were clinically ill, had recent antibiotic use, did not have blood, urine, and CSF data available, or were lost to telephone follow-up at 7 days to ensure wellness. The study cohort included 6,014 infants, 1,233 (32%) who were febrile by history alone. Rates of overall SBI were lower in the afebrile group (8.8% vs. 12.8%). For infants 0-28 days, rates of UTI were lower for the afebrile group (9.5% vs. 14.5%), but there was no difference in the rates of bacteremia or meningitis. For infants 29-60 days, rates of UTI (6.6% vs. 9.3%) and bacteremia (.5% vs. 1.7%) were lower in the afebrile group.
 

Limitations

Neither the use of home antipyretics nor the method of temperature taking at home were studied. Also, as this was a secondary analysis, it is possible that not all infants who presented with history of fever only were captured, as work-up was dictated by individual treating providers who may have chosen not to work up certain afebrile infants.
 

Important findings and implications

Nearly one-third of infants presenting for fever evaluation are afebrile on arrival. Although overall rates of SBI were lower in the group with fever by history only, this difference is largely accounted for by differing rates of UTI. Rates of bacteremia and meningitis remained substantial between groups, particularly for infants aged 0-28 days. Because of the significant morbidity associated with these infections, it is reasonable to suggest that absence of fever on presentation alone should not alter clinical or laboratory work-up, particularly in infants 0-28 days.
 

STUDY 4

Humphrey-Murto S et al. The influence of prior performance information on ratings of current performance and implications for learner handover: A scoping review. Acad Med. 2019 Jul;94(7):1050-7.

Background

Learner Handover (LH) or “forward feeding” occurs when information about trainees is shared between faculty supervisors. Although this can be helpful to tailor educational experiences and build upon previous assessments, it risks stigmatizing trainees and adding bias to future feedback and assessments as the trainee never really has a “clean slate.” In this study, the authors sought to uncover the key concepts of how prior performance information (PPI) influences assessments and any implications for medical education.
 

Study overview and results

The authors performed a cross-disciplinary scoping review looking at over 17,000 articles published between 1980 and 2017 across the domains of psychology, sports, business, and education. Seven themes were identified with the following notable findings. Raters exposed to positive PPI scored a learner’s performance higher, and vice versa. There was a dose-response relationship with more positive and more negative PPI resulting in higher and lower assessments, respectively. General standards, such as a direction to complete all work in a timely manner, caused an assimilation effect, while specific standards, such as a direction to complete a certain task by a certain day, did not. More motivated and more experienced raters are less affected by PPI, and those who believe that people can change (incremental theorists) are less affected by PPI while those who believe personal attributes are fixed (entity theorists) are more affected.
 

Limitations

The heterogeneity of the studies and the fact that they were largely conducted in experimental settings may limit generalizability to medical education. Slightly less than half of the studies included a control arm. Last, most of the studies looked at the ratings of only one target performance, not multiple performances over time.
 

Important findings and implications

Ratings of current performance displace toward PPI direction, with negative PPI more influential than positive PPI. In a formative setting, PPI may help the assessor focus on areas of possible weakness. In contrast, for a summative assessment, PPI may be prejudicial and have an impact on the rating given to the student. Clinicians should be mindful of the information they share with future raters about learners and the potential bias on future assessments that can manifest as a result.
 

STUDY 5

McCann ME et al. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): An international, multicentre, randomised, controlled equivalence trial. The Lancet. 2019 Feb;393:664-77.

Background

Animal models and observational studies have suggested a link between early anesthesia exposure and adverse neurocognitive outcomes; however, findings have been mixed and studies are prone to confounding. This study is the first randomized controlled trial to compare neurocognitive outcomes for infants exposed to general anesthesia versus awake-regional anesthesia.

Study overview and results

In this international, multicenter, assessor-masked trial, 722 infants undergoing inguinal hernia repair were randomized to awake-regional anesthesia or single-agent sevoflurane-based general anesthesia. Infants born at greater than 26 weeks’ gestational age were eligible, while those with prior anesthesia exposure or risks for neurocognitive delay were excluded. The primary outcome was full-scale intelligence quotient (FSIQ) testing at 5 years of age on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III). Seven additional neurodevelopmental assessments and parental questionnaires regarding behavior were administered as secondary outcomes. Average anesthesia exposure was 54 minutes and no infant had exposure greater than 120 minutes. There was no significant difference in mean scores on WPPSI-III FSIQ testing, and no difference in the additional neurocognitive assessments or parent-reported outcomes used as secondary outcomes.
 

Limitations

This study was limited to single, short periods of single-agent anesthesia exposure in children with no additional neurologic risk factors, so caution should be used in extrapolating these data to children with medical complexity and children undergoing multiple procedures, longer surgeries, or multidrug anesthetic regimens. The study population was majority male because of the surgical pathology selected and included only children in the narrow range of postmenstrual age 60 weeks or less. While this population represents a suspected a period of high cerebral vulnerability based on animal models, the implications of anesthesia exposure at other ages are unclear.
 

Important findings and implications

An estimated 10% of children from developed countries are exposed to general anesthesia during the first 3 years of life. While hospitalists do not typically select the route of anesthesia, they frequently care for patients undergoing procedures and must address parental concerns regarding the safety of anesthesia exposure. Given the rigorous study methods and long-term follow up in the current study, these data should provide reassurance that, for healthy infants undergoing short, single-agent anesthetic exposure, there is no evidence of future adverse neurologic outcomes.
 

Dr. Russo is director of pediatrics, medical director for quality and innovation, at WellSpan Health, York, Pa. Dr. Money is a pediatric hospitalist at Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City. Dr. Steed is instructor of hospital medicine, Northwestern Memorial Hospital and Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago. The authors would like to thank Dr. Klint M. Schwenk and the Society for Hospital Medicine Pediatric Special Interest Group Executive Council.

References

1. Roberts KB, Fisher ER, and Rauch DA. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020 Jul;15(7):424-7.

2. Mussman GM and Conway PH. Pediatric hospitalist systems versus traditional models of care: Effect on quality and cost outcomes. J Hosp Med. 2012 Apr;7(4):350-7.

3. Wang ME, Shaughnessy EE, and Leyenaar JK. The future of pediatric hospital medicine: Challenges and opportunities. J Hosp Med. 2020 Jul;15(7):428-30.

4. Chang PW et al. A clinical prediction rule for rebound hyperbilirubinemia following inpatient phototherapy. Pediatrics. 2017;139 Mar;139(3):e20162896.

Like most health care workers at his hospital in Lafayette, Ind., Ramesh Adhikari, MD, FHM, occasionally gets an email noting that a patient he saw later tested positive for COVID-19. He’s reminded to self-monitor for symptoms. But 10 months into the pandemic, it has become increasingly unlikely for contact tracing investigations to result in clinicians quarantining.

The very act of working in the hospital, Dr. Adhikari said, means being likely to see COVID-19 every day, whether in a known patient or an asymptomatic person who tests positive later. If hospitalists had to quarantine after every interaction with a COVID-positive person, there wouldn’t be anyone left to do their jobs.

“It’s really hard to do [contact tracing] in health care workers thoroughly because of the way we work,” Dr. Adhikari said. “It’s impossible to do it absolutely.”

In a recently updated guidance, the Centers for Disease Control and Prevention extended more leeway in contact tracing when community rates of COVID-19 surge, even allowing that contact tracing “may not be possible” in certain situations. And by defining an exposure more narrowly – health care workers are only considered “exposed” if their contact was more than 15 minutes or lacking in some form of PPE – the guidelines suggest that hospitals can rely more on universal PPE and screening protocols, as Dr. Adhikari’s hospital does, and less on extensive contact tracing to curtail viral spread.

Accordingly, while contact tracing has gotten more lax, doctors say, universal precautions – including full PPE and screening of symptoms for patients and health care workers – have become more stringent.

It’s a shift from the beginning of the pandemic. At first, CDC recommended wearing masks only during aerosol-producing procedures. Exposures were frequently reported and health care workers sent home. With more evidence in favor of stricter PPE requirements, hospitals including the one where Shyam Odeti, MD, FHM, works in Johnson City, Tenn., have adopted a universal precaution strategy – requiring masks everywhere and a gown, face shield, gloves, and N95 to enter a COVID-positive patient’s room. Thus, most exposures fall into that low-risk category.

“If I get it and am asymptomatic, I don’t think my colleagues would be exposed by any means because of these stringent policies being enforced,” said Dr. Odeti, a hospitalist who often wears a surgical mask on top of his N95 all day. “And U.S. health care is not in a state that can afford to quarantine health care workers for 14 days.”
 

Can universal PPE precautions supplant contact tracing?

The extent of contact tracing varies by hospital. Larger university and community hospitals often have infection control and occupational health teams that can do their own contact tracing, while smaller institutions can’t always spare staff. And some state health departments get involved with contact tracing of health care workers while others do not.

“I would venture to say that most hospitals are doing something in terms of contact tracing,” said Pam Falk, MPH, CIC, a member of the Association for Professionals in Infection Control and Epidemiology’s COVID-19 task force and an infection control consultant. “It kind of depends on their bandwidth.”

But there’s no longer a norm. Outside of a pandemic, with ample staffing and far fewer instances that need to be investigated, standards for contact tracing are higher, Dr. Falk said: When a patient is found to have an airborne disease such as tuberculosis, measles, mumps, or chickenpox, a hospital’s infection prevention team should investigate, confirm the diagnosis and identify everyone who was exposed. The hospital’s occupational health team assists in deciding who will likely need prophylactic treatment and if employees should be furloughed. The thoroughness of such measures has always depended on a hospital’s bandwidth.

Because PPE seems to be able to contain COVID-19 better than some of the older diseases targeted by contact tracing, universal protections may be a reasonable alternative in current circumstances, doctors said – if PPE is available.

“At the end of the day, universal source control with surgical masks – and ideally eye protection for clinicians as well – should prevent most transmissions,” said Aaron Richterman, MD, from the division of infectious diseases at the Hospital of the University of Pennsylvania, Philadelphia, who coauthored a JAMA commentary on decreased transmission rates in hospitals.

Contact tracing is still useful, though, to identify weaknesses in universal protection measures, he said.

“I don’t think it’s worth abandoning. It’s like a tool in the toolbox. All are imperfect, and none work 100% of the time,” Dr. Richterman said, but using all of them can achieve a fairly high measure of safety. Of the tools, universal masking likely works the best, he contends, so it should be the top pick for hospitals without resources to use all of the tools.

A recent incident at Brigham and Women’s Hospital in Boston is a case study in how contact tracing can work together with universal protections to identify cracks in the system, said Dr. Richterman, who worked at the hospital earlier in the pandemic.

Mass General Brigham adopted a universal masking policy for staff and patients in March 2020. Then, when the system experienced an outbreak in September, the hospital did “a very detailed public evaluation that included contact tracing and universal testing,” Dr. Richterman said. Testing even included genetic analysis of the virus to confirm which cases were hospital acquired. In the end, the hospital identified weaknesses in infection control that could be rectified, such as clinicians eating too close together.

“The approach is not to point fingers, but to say: ‘What’s wrong with the system and how do we improve?’ ” Dr. Richterman said. “To ask, why did that maskless transmission happen? Is there not enough space to eat? Are people working too many hours? It’s useful for systems to understand where transmissions are happening.”

Amith Skandhan, MD, SFHM, a hospitalist in Dothan, Ala., is comfortable without much contact tracing as long as there is universal PPE use. His hospital informs clinicians of exposures, but “basically we’re trained to treat every patient as if they had COVID,” he said, so “I feel more secure in the hospital than in the community.” Masks have become so habitual they’re like part of your regular clothing, he said – you feel incomplete if you don’t have one.

While ad hoc approaches to contact tracing may be useful in the current stage of the pandemic, they are likely to be short-lived: Once a community’s positivity rate falls, the CDC’s guidance suggests how hospitals can return to full contact tracing.

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

Like most health care workers at his hospital in Lafayette, Ind., Ramesh Adhikari, MD, FHM, occasionally gets an email noting that a patient he saw later tested positive for COVID-19. He’s reminded to self-monitor for symptoms. But 10 months into the pandemic, it has become increasingly unlikely for contact tracing investigations to result in clinicians quarantining.

The very act of working in the hospital, Dr. Adhikari said, means being likely to see COVID-19 every day, whether in a known patient or an asymptomatic person who tests positive later. If hospitalists had to quarantine after every interaction with a COVID-positive person, there wouldn’t be anyone left to do their jobs.

“It’s really hard to do [contact tracing] in health care workers thoroughly because of the way we work,” Dr. Adhikari said. “It’s impossible to do it absolutely.”

In a recently updated guidance, the Centers for Disease Control and Prevention extended more leeway in contact tracing when community rates of COVID-19 surge, even allowing that contact tracing “may not be possible” in certain situations. And by defining an exposure more narrowly – health care workers are only considered “exposed” if their contact was more than 15 minutes or lacking in some form of PPE – the guidelines suggest that hospitals can rely more on universal PPE and screening protocols, as Dr. Adhikari’s hospital does, and less on extensive contact tracing to curtail viral spread.

Accordingly, while contact tracing has gotten more lax, doctors say, universal precautions – including full PPE and screening of symptoms for patients and health care workers – have become more stringent.

It’s a shift from the beginning of the pandemic. At first, CDC recommended wearing masks only during aerosol-producing procedures. Exposures were frequently reported and health care workers sent home. With more evidence in favor of stricter PPE requirements, hospitals including the one where Shyam Odeti, MD, FHM, works in Johnson City, Tenn., have adopted a universal precaution strategy – requiring masks everywhere and a gown, face shield, gloves, and N95 to enter a COVID-positive patient’s room. Thus, most exposures fall into that low-risk category.

“If I get it and am asymptomatic, I don’t think my colleagues would be exposed by any means because of these stringent policies being enforced,” said Dr. Odeti, a hospitalist who often wears a surgical mask on top of his N95 all day. “And U.S. health care is not in a state that can afford to quarantine health care workers for 14 days.”
 

Can universal PPE precautions supplant contact tracing?

The extent of contact tracing varies by hospital. Larger university and community hospitals often have infection control and occupational health teams that can do their own contact tracing, while smaller institutions can’t always spare staff. And some state health departments get involved with contact tracing of health care workers while others do not.

“I would venture to say that most hospitals are doing something in terms of contact tracing,” said Pam Falk, MPH, CIC, a member of the Association for Professionals in Infection Control and Epidemiology’s COVID-19 task force and an infection control consultant. “It kind of depends on their bandwidth.”

But there’s no longer a norm. Outside of a pandemic, with ample staffing and far fewer instances that need to be investigated, standards for contact tracing are higher, Dr. Falk said: When a patient is found to have an airborne disease such as tuberculosis, measles, mumps, or chickenpox, a hospital’s infection prevention team should investigate, confirm the diagnosis and identify everyone who was exposed. The hospital’s occupational health team assists in deciding who will likely need prophylactic treatment and if employees should be furloughed. The thoroughness of such measures has always depended on a hospital’s bandwidth.

Because PPE seems to be able to contain COVID-19 better than some of the older diseases targeted by contact tracing, universal protections may be a reasonable alternative in current circumstances, doctors said – if PPE is available.

“At the end of the day, universal source control with surgical masks – and ideally eye protection for clinicians as well – should prevent most transmissions,” said Aaron Richterman, MD, from the division of infectious diseases at the Hospital of the University of Pennsylvania, Philadelphia, who coauthored a JAMA commentary on decreased transmission rates in hospitals.

Contact tracing is still useful, though, to identify weaknesses in universal protection measures, he said.

“I don’t think it’s worth abandoning. It’s like a tool in the toolbox. All are imperfect, and none work 100% of the time,” Dr. Richterman said, but using all of them can achieve a fairly high measure of safety. Of the tools, universal masking likely works the best, he contends, so it should be the top pick for hospitals without resources to use all of the tools.

A recent incident at Brigham and Women’s Hospital in Boston is a case study in how contact tracing can work together with universal protections to identify cracks in the system, said Dr. Richterman, who worked at the hospital earlier in the pandemic.

Mass General Brigham adopted a universal masking policy for staff and patients in March 2020. Then, when the system experienced an outbreak in September, the hospital did “a very detailed public evaluation that included contact tracing and universal testing,” Dr. Richterman said. Testing even included genetic analysis of the virus to confirm which cases were hospital acquired. In the end, the hospital identified weaknesses in infection control that could be rectified, such as clinicians eating too close together.

“The approach is not to point fingers, but to say: ‘What’s wrong with the system and how do we improve?’ ” Dr. Richterman said. “To ask, why did that maskless transmission happen? Is there not enough space to eat? Are people working too many hours? It’s useful for systems to understand where transmissions are happening.”

Amith Skandhan, MD, SFHM, a hospitalist in Dothan, Ala., is comfortable without much contact tracing as long as there is universal PPE use. His hospital informs clinicians of exposures, but “basically we’re trained to treat every patient as if they had COVID,” he said, so “I feel more secure in the hospital than in the community.” Masks have become so habitual they’re like part of your regular clothing, he said – you feel incomplete if you don’t have one.

While ad hoc approaches to contact tracing may be useful in the current stage of the pandemic, they are likely to be short-lived: Once a community’s positivity rate falls, the CDC’s guidance suggests how hospitals can return to full contact tracing.

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

Like most health care workers at his hospital in Lafayette, Ind., Ramesh Adhikari, MD, FHM, occasionally gets an email noting that a patient he saw later tested positive for COVID-19. He’s reminded to self-monitor for symptoms. But 10 months into the pandemic, it has become increasingly unlikely for contact tracing investigations to result in clinicians quarantining.

The very act of working in the hospital, Dr. Adhikari said, means being likely to see COVID-19 every day, whether in a known patient or an asymptomatic person who tests positive later. If hospitalists had to quarantine after every interaction with a COVID-positive person, there wouldn’t be anyone left to do their jobs.

“It’s really hard to do [contact tracing] in health care workers thoroughly because of the way we work,” Dr. Adhikari said. “It’s impossible to do it absolutely.”

In a recently updated guidance, the Centers for Disease Control and Prevention extended more leeway in contact tracing when community rates of COVID-19 surge, even allowing that contact tracing “may not be possible” in certain situations. And by defining an exposure more narrowly – health care workers are only considered “exposed” if their contact was more than 15 minutes or lacking in some form of PPE – the guidelines suggest that hospitals can rely more on universal PPE and screening protocols, as Dr. Adhikari’s hospital does, and less on extensive contact tracing to curtail viral spread.

Accordingly, while contact tracing has gotten more lax, doctors say, universal precautions – including full PPE and screening of symptoms for patients and health care workers – have become more stringent.

It’s a shift from the beginning of the pandemic. At first, CDC recommended wearing masks only during aerosol-producing procedures. Exposures were frequently reported and health care workers sent home. With more evidence in favor of stricter PPE requirements, hospitals including the one where Shyam Odeti, MD, FHM, works in Johnson City, Tenn., have adopted a universal precaution strategy – requiring masks everywhere and a gown, face shield, gloves, and N95 to enter a COVID-positive patient’s room. Thus, most exposures fall into that low-risk category.

“If I get it and am asymptomatic, I don’t think my colleagues would be exposed by any means because of these stringent policies being enforced,” said Dr. Odeti, a hospitalist who often wears a surgical mask on top of his N95 all day. “And U.S. health care is not in a state that can afford to quarantine health care workers for 14 days.”
 

Can universal PPE precautions supplant contact tracing?

The extent of contact tracing varies by hospital. Larger university and community hospitals often have infection control and occupational health teams that can do their own contact tracing, while smaller institutions can’t always spare staff. And some state health departments get involved with contact tracing of health care workers while others do not.

“I would venture to say that most hospitals are doing something in terms of contact tracing,” said Pam Falk, MPH, CIC, a member of the Association for Professionals in Infection Control and Epidemiology’s COVID-19 task force and an infection control consultant. “It kind of depends on their bandwidth.”

But there’s no longer a norm. Outside of a pandemic, with ample staffing and far fewer instances that need to be investigated, standards for contact tracing are higher, Dr. Falk said: When a patient is found to have an airborne disease such as tuberculosis, measles, mumps, or chickenpox, a hospital’s infection prevention team should investigate, confirm the diagnosis and identify everyone who was exposed. The hospital’s occupational health team assists in deciding who will likely need prophylactic treatment and if employees should be furloughed. The thoroughness of such measures has always depended on a hospital’s bandwidth.

Because PPE seems to be able to contain COVID-19 better than some of the older diseases targeted by contact tracing, universal protections may be a reasonable alternative in current circumstances, doctors said – if PPE is available.

“At the end of the day, universal source control with surgical masks – and ideally eye protection for clinicians as well – should prevent most transmissions,” said Aaron Richterman, MD, from the division of infectious diseases at the Hospital of the University of Pennsylvania, Philadelphia, who coauthored a JAMA commentary on decreased transmission rates in hospitals.

Contact tracing is still useful, though, to identify weaknesses in universal protection measures, he said.

“I don’t think it’s worth abandoning. It’s like a tool in the toolbox. All are imperfect, and none work 100% of the time,” Dr. Richterman said, but using all of them can achieve a fairly high measure of safety. Of the tools, universal masking likely works the best, he contends, so it should be the top pick for hospitals without resources to use all of the tools.

A recent incident at Brigham and Women’s Hospital in Boston is a case study in how contact tracing can work together with universal protections to identify cracks in the system, said Dr. Richterman, who worked at the hospital earlier in the pandemic.

Mass General Brigham adopted a universal masking policy for staff and patients in March 2020. Then, when the system experienced an outbreak in September, the hospital did “a very detailed public evaluation that included contact tracing and universal testing,” Dr. Richterman said. Testing even included genetic analysis of the virus to confirm which cases were hospital acquired. In the end, the hospital identified weaknesses in infection control that could be rectified, such as clinicians eating too close together.

“The approach is not to point fingers, but to say: ‘What’s wrong with the system and how do we improve?’ ” Dr. Richterman said. “To ask, why did that maskless transmission happen? Is there not enough space to eat? Are people working too many hours? It’s useful for systems to understand where transmissions are happening.”

Amith Skandhan, MD, SFHM, a hospitalist in Dothan, Ala., is comfortable without much contact tracing as long as there is universal PPE use. His hospital informs clinicians of exposures, but “basically we’re trained to treat every patient as if they had COVID,” he said, so “I feel more secure in the hospital than in the community.” Masks have become so habitual they’re like part of your regular clothing, he said – you feel incomplete if you don’t have one.

While ad hoc approaches to contact tracing may be useful in the current stage of the pandemic, they are likely to be short-lived: Once a community’s positivity rate falls, the CDC’s guidance suggests how hospitals can return to full contact tracing.

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

Fellowship is a time of great growth for pediatric hospital medicine fellows as clinicians, educators, scholars, and as leaders. Leadership is a crucial skill for hospitalists that is cultivated throughout fellowship. As fellows, we step into the role of clinical team leader for the first time and it is our responsibility to create a clinical and educational environment that is safe, inviting and engaging.

For possibly the first time in our careers, pediatric hospital medicine fellows are expected to make final decisions, big and small. We are faced with high-pressure situations almost daily, whether it is a rapid response on a patient, tough diagnostic and therapeutic decisions, difficult conversations with families, or dealing with challenging team members.

Soon after starting fellowship I was faced with a such a situation. The patient was a 6-month-old infant with trisomy 21 who was admitted because of feeding difficulties. They were working on oral feeds but required nasogastric (NG) feeds to meet caloric needs. On my first day on service, the residents indicated that the medical team desired the patient to have a gastrostomy tube (G-tube) placed. I was hoping to send the patient home for a few weeks with the NG tube to see if they were making progress on their oral feeds before deciding on the need for a G-tube. However, the patient’s parents pulled me aside in the hallway and said they were considering a third possibility.

The parents felt strongly about a trial period of a few weeks without the NG tube to see if the patient was able to maintain adequate weight gain with just oral feeds. The bedside nurse reiterated that the family felt their concerns had not been considered up until this point. As the fellow and team leader, it was my job to navigate between my resident team, myself, and the family in order to make a final decision. Through a bedside meeting and shared decision making, we were able to compromise and negotiate a decision, allowing the patient to go home on just oral feeds with close follow-up with their pediatrician. Afterwards, I found myself searching for strategies to be a better leader in these situations.

I found a potential answer in a recent article from the Harvard Business Review titled “What Aircraft Crews Know About Managing High-Pressure Situations.”¹ The article discusses crew resource management (CRM), which was developed in the 1980s and is used in civil and military aviation worldwide. CRM is based on two principles to improve crisis management: The hierarchy on the flight deck must be flattened, and crew members must be actively integrated into the flight’s work flows and decision-making processes.

The authors of the article conducted two different studies to further understand CRM and its effects. The first study included observing 11 flight crews in emergency simulations. In the study, the flight crew had to react to an emergency, and then conduct a landing of the aircraft. What the authors found was that the captain’s style of communication had a major impact on crew performance in two major ways: Crews performed consistently better under times of pressure when the copilot was included in the decision-making process, and captains who asked open-ended questions (“How do you assess the situation”) came up with better solutions than captains who asked “yes or no” questions.

The authors conclude that “involving colleagues as equal decision partners by asking them questions…aids constructive, factual information exchange.” The second study consisted of conducting 61 interviews with flight crew members to better understand crisis management. In the interviews, the same theme occurred, that open-ended questions are vital in all decision-making processes and may be preventative against dangerous or imperfect outcomes. As fellows and team leaders we can learn from CRM and these studies. We need to flatten the hierarchy and ask open-ended questions.

To flatten the hierarchy, we should value the thoughts and opinions of all our team members. Now more than ever in this current COVID-19 pandemic with many hospitals instituting telehealth/telerounding for some or all team members, it is essential to utilize our entire “flight crew” (physicians, nurses, therapists, subspecialists, social worker, case managers, etc.) during routine decisions and high-stake decisions. We should make sure our flight crew, especially the bedside nurse is part of the decision-making process.² This means we need to ensure they are present and given a voice on clinical rounds. To flatten the hierarchy, we must take pride in eliciting other team member’s opinions. We must realize that we alone do not have all the answers, and other team members may have different frameworks in which they process a decision.

Finally, in medicine, our patients and families are included in our flight crew. They too must have a voice in the decision-making process. Previous studies have shown that patients and families desire to be included in the decision-making process, and opportunities exist to improve shared decision-making in pediatrics.^3-5 Lastly, we should commit to asking open-ended questions from our team and our patients. We should value their input and use their answers and frameworks to make the best decision for our patients.

I wasn’t aware at the time, but I was using some of the principles of CRM while navigating my high-pressure situation. A bedside meeting with all team members and the patient’s family helped to flatten the hierarchy by understanding and valuing each team member’s input. Asking open-ended questions of the different team members led to a more inviting and engaging clinical and learning environment. These strategies helped to lead our team into a clinical decision that wasn’t entirely clear at first but ended up being the best decision for the patient, as they are now thriving without ever requiring supplemental nutrition after discharge.

As physicians, we have learned a lot from the airline industry about wellness and the effect of fatigue on performance. It is clear now that we can also learn from them about clinical decision-making and leadership strategies. When adopted for health care, CRM principles have been shown to result in a culture of safety and long-term behavioral change.^6,7 If we can model ourselves after the airline industry by following the principles of CRM, then we will be better clinicians, educators, and leaders.

Dr. Palmer is a second-year pediatric hospital medicine fellow at Children’s Hospital Los Angeles and is working toward a masters in academic medicine at the University of Southern California, Los Angeles, with a focus on curriculum development and educational scholarship production.

References

1. Hagan J et al. What Aircraft Crews Know About Managing High-Pressure Situations. Harvard Business Review. 2019 Dec. https://hbr.org/2019/12/what-aircraft-crews-know-about-managing-high-pressure-situations

2. Erickson J. Bedside nurse involvement in end-of-life decision-making: A brief review of the literature. Dimens Crit Care Nurs. 2013;32(2):65-8.

3. Richards CA et al. Physicians perceptions of shared decision-making in neonatal and pediatric critical care. Am J Hosp Palliat Care. 2018;35(4):669-76.

4. Boland L et al. Barriers and facilitators of pediatric shared decision-making: A systematic review. Implement Sci. 2019 Jan 18. doi: 10.1186/s13012-018-0851-5.

5. Blankenburg R et al. Shared decision-making during inpatient rounds: Opportunities for improvement in patient engagement and communication. J Hosp Med. 2018;13(7):453-61.

6. Kemper PF et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87.

7. Sax HC et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-7.

Fellowship is a time of great growth for pediatric hospital medicine fellows as clinicians, educators, scholars, and as leaders. Leadership is a crucial skill for hospitalists that is cultivated throughout fellowship. As fellows, we step into the role of clinical team leader for the first time and it is our responsibility to create a clinical and educational environment that is safe, inviting and engaging.

For possibly the first time in our careers, pediatric hospital medicine fellows are expected to make final decisions, big and small. We are faced with high-pressure situations almost daily, whether it is a rapid response on a patient, tough diagnostic and therapeutic decisions, difficult conversations with families, or dealing with challenging team members.

Soon after starting fellowship I was faced with a such a situation. The patient was a 6-month-old infant with trisomy 21 who was admitted because of feeding difficulties. They were working on oral feeds but required nasogastric (NG) feeds to meet caloric needs. On my first day on service, the residents indicated that the medical team desired the patient to have a gastrostomy tube (G-tube) placed. I was hoping to send the patient home for a few weeks with the NG tube to see if they were making progress on their oral feeds before deciding on the need for a G-tube. However, the patient’s parents pulled me aside in the hallway and said they were considering a third possibility.

The parents felt strongly about a trial period of a few weeks without the NG tube to see if the patient was able to maintain adequate weight gain with just oral feeds. The bedside nurse reiterated that the family felt their concerns had not been considered up until this point. As the fellow and team leader, it was my job to navigate between my resident team, myself, and the family in order to make a final decision. Through a bedside meeting and shared decision making, we were able to compromise and negotiate a decision, allowing the patient to go home on just oral feeds with close follow-up with their pediatrician. Afterwards, I found myself searching for strategies to be a better leader in these situations.

I found a potential answer in a recent article from the Harvard Business Review titled “What Aircraft Crews Know About Managing High-Pressure Situations.”¹ The article discusses crew resource management (CRM), which was developed in the 1980s and is used in civil and military aviation worldwide. CRM is based on two principles to improve crisis management: The hierarchy on the flight deck must be flattened, and crew members must be actively integrated into the flight’s work flows and decision-making processes.

The authors of the article conducted two different studies to further understand CRM and its effects. The first study included observing 11 flight crews in emergency simulations. In the study, the flight crew had to react to an emergency, and then conduct a landing of the aircraft. What the authors found was that the captain’s style of communication had a major impact on crew performance in two major ways: Crews performed consistently better under times of pressure when the copilot was included in the decision-making process, and captains who asked open-ended questions (“How do you assess the situation”) came up with better solutions than captains who asked “yes or no” questions.

The authors conclude that “involving colleagues as equal decision partners by asking them questions…aids constructive, factual information exchange.” The second study consisted of conducting 61 interviews with flight crew members to better understand crisis management. In the interviews, the same theme occurred, that open-ended questions are vital in all decision-making processes and may be preventative against dangerous or imperfect outcomes. As fellows and team leaders we can learn from CRM and these studies. We need to flatten the hierarchy and ask open-ended questions.

To flatten the hierarchy, we should value the thoughts and opinions of all our team members. Now more than ever in this current COVID-19 pandemic with many hospitals instituting telehealth/telerounding for some or all team members, it is essential to utilize our entire “flight crew” (physicians, nurses, therapists, subspecialists, social worker, case managers, etc.) during routine decisions and high-stake decisions. We should make sure our flight crew, especially the bedside nurse is part of the decision-making process.² This means we need to ensure they are present and given a voice on clinical rounds. To flatten the hierarchy, we must take pride in eliciting other team member’s opinions. We must realize that we alone do not have all the answers, and other team members may have different frameworks in which they process a decision.

Finally, in medicine, our patients and families are included in our flight crew. They too must have a voice in the decision-making process. Previous studies have shown that patients and families desire to be included in the decision-making process, and opportunities exist to improve shared decision-making in pediatrics.^3-5 Lastly, we should commit to asking open-ended questions from our team and our patients. We should value their input and use their answers and frameworks to make the best decision for our patients.

I wasn’t aware at the time, but I was using some of the principles of CRM while navigating my high-pressure situation. A bedside meeting with all team members and the patient’s family helped to flatten the hierarchy by understanding and valuing each team member’s input. Asking open-ended questions of the different team members led to a more inviting and engaging clinical and learning environment. These strategies helped to lead our team into a clinical decision that wasn’t entirely clear at first but ended up being the best decision for the patient, as they are now thriving without ever requiring supplemental nutrition after discharge.

As physicians, we have learned a lot from the airline industry about wellness and the effect of fatigue on performance. It is clear now that we can also learn from them about clinical decision-making and leadership strategies. When adopted for health care, CRM principles have been shown to result in a culture of safety and long-term behavioral change.^6,7 If we can model ourselves after the airline industry by following the principles of CRM, then we will be better clinicians, educators, and leaders.

Dr. Palmer is a second-year pediatric hospital medicine fellow at Children’s Hospital Los Angeles and is working toward a masters in academic medicine at the University of Southern California, Los Angeles, with a focus on curriculum development and educational scholarship production.

References

1. Hagan J et al. What Aircraft Crews Know About Managing High-Pressure Situations. Harvard Business Review. 2019 Dec. https://hbr.org/2019/12/what-aircraft-crews-know-about-managing-high-pressure-situations

2. Erickson J. Bedside nurse involvement in end-of-life decision-making: A brief review of the literature. Dimens Crit Care Nurs. 2013;32(2):65-8.

3. Richards CA et al. Physicians perceptions of shared decision-making in neonatal and pediatric critical care. Am J Hosp Palliat Care. 2018;35(4):669-76.

4. Boland L et al. Barriers and facilitators of pediatric shared decision-making: A systematic review. Implement Sci. 2019 Jan 18. doi: 10.1186/s13012-018-0851-5.

5. Blankenburg R et al. Shared decision-making during inpatient rounds: Opportunities for improvement in patient engagement and communication. J Hosp Med. 2018;13(7):453-61.

6. Kemper PF et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87.

7. Sax HC et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-7.

Fellowship is a time of great growth for pediatric hospital medicine fellows as clinicians, educators, scholars, and as leaders. Leadership is a crucial skill for hospitalists that is cultivated throughout fellowship. As fellows, we step into the role of clinical team leader for the first time and it is our responsibility to create a clinical and educational environment that is safe, inviting and engaging.

For possibly the first time in our careers, pediatric hospital medicine fellows are expected to make final decisions, big and small. We are faced with high-pressure situations almost daily, whether it is a rapid response on a patient, tough diagnostic and therapeutic decisions, difficult conversations with families, or dealing with challenging team members.

Soon after starting fellowship I was faced with a such a situation. The patient was a 6-month-old infant with trisomy 21 who was admitted because of feeding difficulties. They were working on oral feeds but required nasogastric (NG) feeds to meet caloric needs. On my first day on service, the residents indicated that the medical team desired the patient to have a gastrostomy tube (G-tube) placed. I was hoping to send the patient home for a few weeks with the NG tube to see if they were making progress on their oral feeds before deciding on the need for a G-tube. However, the patient’s parents pulled me aside in the hallway and said they were considering a third possibility.

The parents felt strongly about a trial period of a few weeks without the NG tube to see if the patient was able to maintain adequate weight gain with just oral feeds. The bedside nurse reiterated that the family felt their concerns had not been considered up until this point. As the fellow and team leader, it was my job to navigate between my resident team, myself, and the family in order to make a final decision. Through a bedside meeting and shared decision making, we were able to compromise and negotiate a decision, allowing the patient to go home on just oral feeds with close follow-up with their pediatrician. Afterwards, I found myself searching for strategies to be a better leader in these situations.

I found a potential answer in a recent article from the Harvard Business Review titled “What Aircraft Crews Know About Managing High-Pressure Situations.”¹ The article discusses crew resource management (CRM), which was developed in the 1980s and is used in civil and military aviation worldwide. CRM is based on two principles to improve crisis management: The hierarchy on the flight deck must be flattened, and crew members must be actively integrated into the flight’s work flows and decision-making processes.

The authors of the article conducted two different studies to further understand CRM and its effects. The first study included observing 11 flight crews in emergency simulations. In the study, the flight crew had to react to an emergency, and then conduct a landing of the aircraft. What the authors found was that the captain’s style of communication had a major impact on crew performance in two major ways: Crews performed consistently better under times of pressure when the copilot was included in the decision-making process, and captains who asked open-ended questions (“How do you assess the situation”) came up with better solutions than captains who asked “yes or no” questions.

The authors conclude that “involving colleagues as equal decision partners by asking them questions…aids constructive, factual information exchange.” The second study consisted of conducting 61 interviews with flight crew members to better understand crisis management. In the interviews, the same theme occurred, that open-ended questions are vital in all decision-making processes and may be preventative against dangerous or imperfect outcomes. As fellows and team leaders we can learn from CRM and these studies. We need to flatten the hierarchy and ask open-ended questions.

To flatten the hierarchy, we should value the thoughts and opinions of all our team members. Now more than ever in this current COVID-19 pandemic with many hospitals instituting telehealth/telerounding for some or all team members, it is essential to utilize our entire “flight crew” (physicians, nurses, therapists, subspecialists, social worker, case managers, etc.) during routine decisions and high-stake decisions. We should make sure our flight crew, especially the bedside nurse is part of the decision-making process.² This means we need to ensure they are present and given a voice on clinical rounds. To flatten the hierarchy, we must take pride in eliciting other team member’s opinions. We must realize that we alone do not have all the answers, and other team members may have different frameworks in which they process a decision.

Finally, in medicine, our patients and families are included in our flight crew. They too must have a voice in the decision-making process. Previous studies have shown that patients and families desire to be included in the decision-making process, and opportunities exist to improve shared decision-making in pediatrics.^3-5 Lastly, we should commit to asking open-ended questions from our team and our patients. We should value their input and use their answers and frameworks to make the best decision for our patients.

I wasn’t aware at the time, but I was using some of the principles of CRM while navigating my high-pressure situation. A bedside meeting with all team members and the patient’s family helped to flatten the hierarchy by understanding and valuing each team member’s input. Asking open-ended questions of the different team members led to a more inviting and engaging clinical and learning environment. These strategies helped to lead our team into a clinical decision that wasn’t entirely clear at first but ended up being the best decision for the patient, as they are now thriving without ever requiring supplemental nutrition after discharge.

As physicians, we have learned a lot from the airline industry about wellness and the effect of fatigue on performance. It is clear now that we can also learn from them about clinical decision-making and leadership strategies. When adopted for health care, CRM principles have been shown to result in a culture of safety and long-term behavioral change.^6,7 If we can model ourselves after the airline industry by following the principles of CRM, then we will be better clinicians, educators, and leaders.

Dr. Palmer is a second-year pediatric hospital medicine fellow at Children’s Hospital Los Angeles and is working toward a masters in academic medicine at the University of Southern California, Los Angeles, with a focus on curriculum development and educational scholarship production.

References

1. Hagan J et al. What Aircraft Crews Know About Managing High-Pressure Situations. Harvard Business Review. 2019 Dec. https://hbr.org/2019/12/what-aircraft-crews-know-about-managing-high-pressure-situations

2. Erickson J. Bedside nurse involvement in end-of-life decision-making: A brief review of the literature. Dimens Crit Care Nurs. 2013;32(2):65-8.

3. Richards CA et al. Physicians perceptions of shared decision-making in neonatal and pediatric critical care. Am J Hosp Palliat Care. 2018;35(4):669-76.

4. Boland L et al. Barriers and facilitators of pediatric shared decision-making: A systematic review. Implement Sci. 2019 Jan 18. doi: 10.1186/s13012-018-0851-5.

5. Blankenburg R et al. Shared decision-making during inpatient rounds: Opportunities for improvement in patient engagement and communication. J Hosp Med. 2018;13(7):453-61.

6. Kemper PF et al. Crew resource management training in the intensive care unit. A multisite controlled before-after study. BMJ Qual Saf. 2016;25(8):577-87.

7. Sax HC et al. Can aviation-based team training elicit sustainable behavioral change? Arch Surg. 2009;144(12):1133-7.

As an aspiring physician, I like learning about how things work. Since medical students learn very little about the “business” of medicine in school, this led me to pioneer a project on missed billing by hospitalists at a medium-sized hospital in the northeastern US. Although hospitalists do a tremendous amount of work, they do not always bill for what they are doing. The question became: Why are hospitalists missing charges and what can we do to stop it?

Shortly into my study, I recognized there was little daily communication between the administrators and the hospitalists; neither the hospitalists nor administrators understood the different dynamics that the others faced in their own workplace. It became apparent that administrators needed to learn what was important to hospitalists and to address them at their level in order to bring about change.

Some trending themes emerged as I started shadowing the hospitalists. Many of them asked how this project would benefit them. They argued that administrative needs should be dealt with at the administrative level. A major point was made that current incentives, such as the bonuses given for exceeding a certain number of RVUs, were not the motivating force behind their work ethics. From my observations, the motivating factors were the quality of their patient care, the needs of their patients, and teaching. The hospitalists also were eager to teach and continually instructed me on clinical skills and how to be a better medical student.

Bonuses or notoriety didn’t seem to be the main incentives for them. However, efficiency – especially in rounding – was important, and that became the focal point of the project. I found several studies that showed that improvements in aspects of rounding led to increased quality of patient care, decreased burnout, increased patient satisfaction, and decreased workload and discussed some of those findings with the hospitalists.^1-10 When the hospitalists felt that their concerns were being heard, they became even more involved in the project, and the administrators and hospitalists started working together as a team.

One hospitalist spent two hours helping me design the platform that would be used for hospitalists to report barriers in their rounding process that may cause them to miss a charge. Once we identified those barriers, we discussed the possibility of standardizing their workflow based off these data. Many hospitalists argued that each physician has unique skills and practices that make them successful; therefore, the disruption of an already established workflow may cause a decrease in efficiency.

The hospitalists and I talked a lot about the importance of them rounding more efficiently and how that could positively affect the time that they have with their patients and themselves. We discussed that due to the additional work missed billing causes, minimizing this burden can possibly help decrease burnout. As a result, seven hospitalists, the administrative staff, and I met and created thirteen best practices, six of which they were able to get approved to use immediately. To note, hospitalists bill differently; some use a software company, fill out paper forms still or have integration within their EMR. Although these solutions were made for a program which has the ability to bill within the EMR, many of the principles will apply to your program too.

When a doctor signs a note, it opens a charge option or there is a hard stop.

Charge delinquencies are sent via email to the hospitalist.

Standardize that hospitalists charge directly after writing a note consistently as part of their workflow.*

Prioritize discharges before rounding.*

Standardize the use of the “my prof charges” column, a feature of this hospital’s EMR system that tells them if they had made a charge to a patient or not, in order to remind them to/confirm billing a patient.*

Create reports by the EMR system to provide charge data for individual providers.

Create a report for bill vs note to help providers self-audit. At this hospital, this feature was offered to the administrators as a way to audit their providers and doctors.

Ensure that when a patient is seen by a physician hospitalist as well as an NP/PA hospitalist, the appropriate charge for the physician is entered.

Notifications get sent to the physician hospitalist if a charge gets deleted by another person (e.g., NP/PA hospitalist).

Handoff of daily rounding sheets, or a paper copy of the patients assigned to a hospitalist for his/her shift, at the end of the shift to the project specialist.*

To keep the rounding sheets a complete and accurate account of the patients seen by the hospitalist.*

Hospitalists are to complete and check all billing at the end of their shift at the latest.*

Hospitalists are to participate on Provider Efficiency Training to optimize workflow, by creating more efficient note-writing behavior using Dragon.

*Indicates the practices the hospitalists were able to implement immediately. Practices 1, 2, 6, 7, and 9 request EMR changes. Practice 8 was already an established practice the hospitalists wished to continue. Practice 13 was suggested by the Lean Director for the continuation of a previous project.


Six of the best practices were easier to implement right away because they were at the discretion of the hospitalists. We found that the hospitalists who had the highest billing performances were more likely to start writing notes and charge earlier while rounding. Those who had poorer billing performances were more likely to leave all note writing and billing towards the end of their shift. The few exceptions (hospitalists who left all note writing and charging to the end of their shift yet had high billing performances) were found to have a consistent and standardized workflow. This was unlike the hospitalists who had the lowest billing performances. Having practices that help remind hospitalists to bill will surely help prevent missed billing, but because of the findings from this project, it was important to have consistent and standardized practices to additionally improve missed billing.

• Hospitalists favor solutions that benefit them or their patients.
• Hospitalists want to be part of the solution process.
• Hospitalists were more likely to accept ideas to improve their rounding if it meant they could keep their routine.

Obstacles exist in our health care system that prevent administrators and hospitalists from working together as a team. The more we are able to communicate and collaborate to fix problems in the health system, the more we can use the system to our mutual advantage. With the ongoing changes in medicine, especially during uncertain times, better communication needs be a major priority to affect positive change.

Ms. Mirabella attends the Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, Conn., in the class of 2022. She has interests in internal/hospital medicine, primary care, and health management and leadership. Dr. Rosenberg is associate professor at the Frank H. Netter MD School of Medicine at Quinnipiac University where she is director of clinical skills coaching. Dr. Kiassat is associate dean of the School of Engineering and associate clinical professor at Frank H. Netter MD School of Medicine, at Quinnipiac University. His research interests are in process improvement in health care, using Lean Six Sigma.

References

1. Burdick K, et al. Bedside interprofessional rounding. J Patient Exp. 2017;4(1):22-27. doi: 10.1177/2374373517692910.

2. Patel CR. Improving communication between hospitalists and consultants. The Hospital Leader. 2018. https://thehospitalleader.org/improving-communication-between-hospitalists-and-consultants/.

3. Adams TN, et al. Hospitalist perspective of interactions with medicine subspecialty consult services. J Hosp Med. 2018;13(5):318-323. doi: 10.12788/jhm.2882.

4. Michtalik HJ, et al. Impact of attending physician workload on patient care: A survey of hospitalists. JAMA Intern Med. 2013;173(5):375-377. doi: 10.1001/jamainternmed.2013.1864.

5. Chandra R, et al. How hospitalists can improve efficiency on inpatient wards. The Hospitalist. 2014. https://www.the-hospitalist.org/hospitalist/article/126231/how-hospitalists-can-improve-efficiency-inpatient-wards.

6. Chand DV. Observational study using the tools of lean six sigma to improve the efficiency of the resident rounding process. J Grad Med Educ. 2011;3(2):144-150. doi: 10.4300/JGME-D-10-00116.1.

7. O’Leary KJ, et al. How hospitalists spend their time: Insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93. doi: 10.1002/jhm.88.

8. Wachter RM. Hospitalist workload: The search for the magic number. JAMA Intern Med. 2014;174(5):794-795. doi: 10.1001/jamainternmed.2014.18.

9. Bryson C, et al. Geographical assignment of hospitalists in an urban teaching hospital: Feasibility and impact on efficiency and provider satisfaction. Hospital Practice. 2017;45(4):135-142. doi: 10.1080/21548331.2017.1353884.

10. Calderon AS, et al. Transforming ward rounds through rounding-in-flow. J Grad Med Educ. 2014 Dec;6(4):750-5. doi: 10.4300/JGME-D-13-00324.1.

As an aspiring physician, I like learning about how things work. Since medical students learn very little about the “business” of medicine in school, this led me to pioneer a project on missed billing by hospitalists at a medium-sized hospital in the northeastern US. Although hospitalists do a tremendous amount of work, they do not always bill for what they are doing. The question became: Why are hospitalists missing charges and what can we do to stop it?

Shortly into my study, I recognized there was little daily communication between the administrators and the hospitalists; neither the hospitalists nor administrators understood the different dynamics that the others faced in their own workplace. It became apparent that administrators needed to learn what was important to hospitalists and to address them at their level in order to bring about change.

Some trending themes emerged as I started shadowing the hospitalists. Many of them asked how this project would benefit them. They argued that administrative needs should be dealt with at the administrative level. A major point was made that current incentives, such as the bonuses given for exceeding a certain number of RVUs, were not the motivating force behind their work ethics. From my observations, the motivating factors were the quality of their patient care, the needs of their patients, and teaching. The hospitalists also were eager to teach and continually instructed me on clinical skills and how to be a better medical student.

Bonuses or notoriety didn’t seem to be the main incentives for them. However, efficiency – especially in rounding – was important, and that became the focal point of the project. I found several studies that showed that improvements in aspects of rounding led to increased quality of patient care, decreased burnout, increased patient satisfaction, and decreased workload and discussed some of those findings with the hospitalists.^1-10 When the hospitalists felt that their concerns were being heard, they became even more involved in the project, and the administrators and hospitalists started working together as a team.

One hospitalist spent two hours helping me design the platform that would be used for hospitalists to report barriers in their rounding process that may cause them to miss a charge. Once we identified those barriers, we discussed the possibility of standardizing their workflow based off these data. Many hospitalists argued that each physician has unique skills and practices that make them successful; therefore, the disruption of an already established workflow may cause a decrease in efficiency.

The hospitalists and I talked a lot about the importance of them rounding more efficiently and how that could positively affect the time that they have with their patients and themselves. We discussed that due to the additional work missed billing causes, minimizing this burden can possibly help decrease burnout. As a result, seven hospitalists, the administrative staff, and I met and created thirteen best practices, six of which they were able to get approved to use immediately. To note, hospitalists bill differently; some use a software company, fill out paper forms still or have integration within their EMR. Although these solutions were made for a program which has the ability to bill within the EMR, many of the principles will apply to your program too.

When a doctor signs a note, it opens a charge option or there is a hard stop.

Charge delinquencies are sent via email to the hospitalist.

Standardize that hospitalists charge directly after writing a note consistently as part of their workflow.*

Prioritize discharges before rounding.*

Standardize the use of the “my prof charges” column, a feature of this hospital’s EMR system that tells them if they had made a charge to a patient or not, in order to remind them to/confirm billing a patient.*

Create reports by the EMR system to provide charge data for individual providers.

Create a report for bill vs note to help providers self-audit. At this hospital, this feature was offered to the administrators as a way to audit their providers and doctors.

Ensure that when a patient is seen by a physician hospitalist as well as an NP/PA hospitalist, the appropriate charge for the physician is entered.

Notifications get sent to the physician hospitalist if a charge gets deleted by another person (e.g., NP/PA hospitalist).

Handoff of daily rounding sheets, or a paper copy of the patients assigned to a hospitalist for his/her shift, at the end of the shift to the project specialist.*

To keep the rounding sheets a complete and accurate account of the patients seen by the hospitalist.*

Hospitalists are to complete and check all billing at the end of their shift at the latest.*

Hospitalists are to participate on Provider Efficiency Training to optimize workflow, by creating more efficient note-writing behavior using Dragon.

*Indicates the practices the hospitalists were able to implement immediately. Practices 1, 2, 6, 7, and 9 request EMR changes. Practice 8 was already an established practice the hospitalists wished to continue. Practice 13 was suggested by the Lean Director for the continuation of a previous project.


Six of the best practices were easier to implement right away because they were at the discretion of the hospitalists. We found that the hospitalists who had the highest billing performances were more likely to start writing notes and charge earlier while rounding. Those who had poorer billing performances were more likely to leave all note writing and billing towards the end of their shift. The few exceptions (hospitalists who left all note writing and charging to the end of their shift yet had high billing performances) were found to have a consistent and standardized workflow. This was unlike the hospitalists who had the lowest billing performances. Having practices that help remind hospitalists to bill will surely help prevent missed billing, but because of the findings from this project, it was important to have consistent and standardized practices to additionally improve missed billing.

• Hospitalists favor solutions that benefit them or their patients.
• Hospitalists want to be part of the solution process.
• Hospitalists were more likely to accept ideas to improve their rounding if it meant they could keep their routine.

Obstacles exist in our health care system that prevent administrators and hospitalists from working together as a team. The more we are able to communicate and collaborate to fix problems in the health system, the more we can use the system to our mutual advantage. With the ongoing changes in medicine, especially during uncertain times, better communication needs be a major priority to affect positive change.

Ms. Mirabella attends the Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, Conn., in the class of 2022. She has interests in internal/hospital medicine, primary care, and health management and leadership. Dr. Rosenberg is associate professor at the Frank H. Netter MD School of Medicine at Quinnipiac University where she is director of clinical skills coaching. Dr. Kiassat is associate dean of the School of Engineering and associate clinical professor at Frank H. Netter MD School of Medicine, at Quinnipiac University. His research interests are in process improvement in health care, using Lean Six Sigma.

References

1. Burdick K, et al. Bedside interprofessional rounding. J Patient Exp. 2017;4(1):22-27. doi: 10.1177/2374373517692910.

2. Patel CR. Improving communication between hospitalists and consultants. The Hospital Leader. 2018. https://thehospitalleader.org/improving-communication-between-hospitalists-and-consultants/.

3. Adams TN, et al. Hospitalist perspective of interactions with medicine subspecialty consult services. J Hosp Med. 2018;13(5):318-323. doi: 10.12788/jhm.2882.

4. Michtalik HJ, et al. Impact of attending physician workload on patient care: A survey of hospitalists. JAMA Intern Med. 2013;173(5):375-377. doi: 10.1001/jamainternmed.2013.1864.

5. Chandra R, et al. How hospitalists can improve efficiency on inpatient wards. The Hospitalist. 2014. https://www.the-hospitalist.org/hospitalist/article/126231/how-hospitalists-can-improve-efficiency-inpatient-wards.

6. Chand DV. Observational study using the tools of lean six sigma to improve the efficiency of the resident rounding process. J Grad Med Educ. 2011;3(2):144-150. doi: 10.4300/JGME-D-10-00116.1.

7. O’Leary KJ, et al. How hospitalists spend their time: Insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93. doi: 10.1002/jhm.88.

8. Wachter RM. Hospitalist workload: The search for the magic number. JAMA Intern Med. 2014;174(5):794-795. doi: 10.1001/jamainternmed.2014.18.

9. Bryson C, et al. Geographical assignment of hospitalists in an urban teaching hospital: Feasibility and impact on efficiency and provider satisfaction. Hospital Practice. 2017;45(4):135-142. doi: 10.1080/21548331.2017.1353884.

10. Calderon AS, et al. Transforming ward rounds through rounding-in-flow. J Grad Med Educ. 2014 Dec;6(4):750-5. doi: 10.4300/JGME-D-13-00324.1.

As an aspiring physician, I like learning about how things work. Since medical students learn very little about the “business” of medicine in school, this led me to pioneer a project on missed billing by hospitalists at a medium-sized hospital in the northeastern US. Although hospitalists do a tremendous amount of work, they do not always bill for what they are doing. The question became: Why are hospitalists missing charges and what can we do to stop it?

Shortly into my study, I recognized there was little daily communication between the administrators and the hospitalists; neither the hospitalists nor administrators understood the different dynamics that the others faced in their own workplace. It became apparent that administrators needed to learn what was important to hospitalists and to address them at their level in order to bring about change.

Some trending themes emerged as I started shadowing the hospitalists. Many of them asked how this project would benefit them. They argued that administrative needs should be dealt with at the administrative level. A major point was made that current incentives, such as the bonuses given for exceeding a certain number of RVUs, were not the motivating force behind their work ethics. From my observations, the motivating factors were the quality of their patient care, the needs of their patients, and teaching. The hospitalists also were eager to teach and continually instructed me on clinical skills and how to be a better medical student.

Bonuses or notoriety didn’t seem to be the main incentives for them. However, efficiency – especially in rounding – was important, and that became the focal point of the project. I found several studies that showed that improvements in aspects of rounding led to increased quality of patient care, decreased burnout, increased patient satisfaction, and decreased workload and discussed some of those findings with the hospitalists.^1-10 When the hospitalists felt that their concerns were being heard, they became even more involved in the project, and the administrators and hospitalists started working together as a team.

One hospitalist spent two hours helping me design the platform that would be used for hospitalists to report barriers in their rounding process that may cause them to miss a charge. Once we identified those barriers, we discussed the possibility of standardizing their workflow based off these data. Many hospitalists argued that each physician has unique skills and practices that make them successful; therefore, the disruption of an already established workflow may cause a decrease in efficiency.

The hospitalists and I talked a lot about the importance of them rounding more efficiently and how that could positively affect the time that they have with their patients and themselves. We discussed that due to the additional work missed billing causes, minimizing this burden can possibly help decrease burnout. As a result, seven hospitalists, the administrative staff, and I met and created thirteen best practices, six of which they were able to get approved to use immediately. To note, hospitalists bill differently; some use a software company, fill out paper forms still or have integration within their EMR. Although these solutions were made for a program which has the ability to bill within the EMR, many of the principles will apply to your program too.

When a doctor signs a note, it opens a charge option or there is a hard stop.

Charge delinquencies are sent via email to the hospitalist.

Standardize that hospitalists charge directly after writing a note consistently as part of their workflow.*

Prioritize discharges before rounding.*

Standardize the use of the “my prof charges” column, a feature of this hospital’s EMR system that tells them if they had made a charge to a patient or not, in order to remind them to/confirm billing a patient.*

Create reports by the EMR system to provide charge data for individual providers.

Create a report for bill vs note to help providers self-audit. At this hospital, this feature was offered to the administrators as a way to audit their providers and doctors.

Ensure that when a patient is seen by a physician hospitalist as well as an NP/PA hospitalist, the appropriate charge for the physician is entered.

Notifications get sent to the physician hospitalist if a charge gets deleted by another person (e.g., NP/PA hospitalist).

Handoff of daily rounding sheets, or a paper copy of the patients assigned to a hospitalist for his/her shift, at the end of the shift to the project specialist.*

To keep the rounding sheets a complete and accurate account of the patients seen by the hospitalist.*

Hospitalists are to complete and check all billing at the end of their shift at the latest.*

Hospitalists are to participate on Provider Efficiency Training to optimize workflow, by creating more efficient note-writing behavior using Dragon.

*Indicates the practices the hospitalists were able to implement immediately. Practices 1, 2, 6, 7, and 9 request EMR changes. Practice 8 was already an established practice the hospitalists wished to continue. Practice 13 was suggested by the Lean Director for the continuation of a previous project.


Six of the best practices were easier to implement right away because they were at the discretion of the hospitalists. We found that the hospitalists who had the highest billing performances were more likely to start writing notes and charge earlier while rounding. Those who had poorer billing performances were more likely to leave all note writing and billing towards the end of their shift. The few exceptions (hospitalists who left all note writing and charging to the end of their shift yet had high billing performances) were found to have a consistent and standardized workflow. This was unlike the hospitalists who had the lowest billing performances. Having practices that help remind hospitalists to bill will surely help prevent missed billing, but because of the findings from this project, it was important to have consistent and standardized practices to additionally improve missed billing.

• Hospitalists favor solutions that benefit them or their patients.
• Hospitalists want to be part of the solution process.
• Hospitalists were more likely to accept ideas to improve their rounding if it meant they could keep their routine.

Obstacles exist in our health care system that prevent administrators and hospitalists from working together as a team. The more we are able to communicate and collaborate to fix problems in the health system, the more we can use the system to our mutual advantage. With the ongoing changes in medicine, especially during uncertain times, better communication needs be a major priority to affect positive change.

Ms. Mirabella attends the Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, Conn., in the class of 2022. She has interests in internal/hospital medicine, primary care, and health management and leadership. Dr. Rosenberg is associate professor at the Frank H. Netter MD School of Medicine at Quinnipiac University where she is director of clinical skills coaching. Dr. Kiassat is associate dean of the School of Engineering and associate clinical professor at Frank H. Netter MD School of Medicine, at Quinnipiac University. His research interests are in process improvement in health care, using Lean Six Sigma.

References

1. Burdick K, et al. Bedside interprofessional rounding. J Patient Exp. 2017;4(1):22-27. doi: 10.1177/2374373517692910.

2. Patel CR. Improving communication between hospitalists and consultants. The Hospital Leader. 2018. https://thehospitalleader.org/improving-communication-between-hospitalists-and-consultants/.

3. Adams TN, et al. Hospitalist perspective of interactions with medicine subspecialty consult services. J Hosp Med. 2018;13(5):318-323. doi: 10.12788/jhm.2882.

4. Michtalik HJ, et al. Impact of attending physician workload on patient care: A survey of hospitalists. JAMA Intern Med. 2013;173(5):375-377. doi: 10.1001/jamainternmed.2013.1864.

5. Chandra R, et al. How hospitalists can improve efficiency on inpatient wards. The Hospitalist. 2014. https://www.the-hospitalist.org/hospitalist/article/126231/how-hospitalists-can-improve-efficiency-inpatient-wards.

6. Chand DV. Observational study using the tools of lean six sigma to improve the efficiency of the resident rounding process. J Grad Med Educ. 2011;3(2):144-150. doi: 10.4300/JGME-D-10-00116.1.

7. O’Leary KJ, et al. How hospitalists spend their time: Insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93. doi: 10.1002/jhm.88.

8. Wachter RM. Hospitalist workload: The search for the magic number. JAMA Intern Med. 2014;174(5):794-795. doi: 10.1001/jamainternmed.2014.18.

9. Bryson C, et al. Geographical assignment of hospitalists in an urban teaching hospital: Feasibility and impact on efficiency and provider satisfaction. Hospital Practice. 2017;45(4):135-142. doi: 10.1080/21548331.2017.1353884.

10. Calderon AS, et al. Transforming ward rounds through rounding-in-flow. J Grad Med Educ. 2014 Dec;6(4):750-5. doi: 10.4300/JGME-D-13-00324.1.

A family medicine trained doctor, fresh out of residency, visits a career website to scout out prospective hospitalist jobs in their region. As they scroll through the job listings, they come across one opportunity at a nearby hospital system that seems like a good fit. The listing offers a competitive salary and comprehensive benefits for the position, and mentions hospitalists in the department will have the opportunity to teach medical students.

The only problem? The position is for internal medicine trained doctors only. After searching through several more listings with the same internal medicine requirement, the pool of jobs available to the family medicine doctor seems much smaller.
When Robert M. Wachter, MD, MHM, and Lee Goldman, MD coined the term “hospitalist” in a 1996 New England Journal of Medicine article, hospitalists were primarily clinicians with an internal medicine background, filling the gap created by family medicine doctors who increasingly devoted their time to patients in their practice and spent less time rounding in the hospital.
As family medicine doctors have returned to hospital medicine, it has become difficult to find positions as hospitalists due to a preference by some recruiters and employers that favors internal medicine physicians over those who are trained in family medicine. The preference for internal medicine physicians is sometimes overt, such as a requirement on a job application. But the preference can also surface after a physician has already applied for a position, and they will then discover a recruiter is actually looking for someone with a background in internal medicine. In other cases, family medicine physicians find out after applying that applicants with a background in family medicine are considered, but they’re expected to have additional training or certification not listed on the job application. 
The situation can even be as stark as a hospital system hiring an internal medicine doctor just out of residency over a family medicine doctor with years of experience as a board-certified physician. Hiring practices in large systems across multiple states sometimes don’t just favor internal medicine, they are entirely focused on internal medicine hospitalists, said experts who spoke with The Hospitalist.

Outdated perceptions of family medicine

Victoria McCurry, MD, current chair of the Society of Hospital Medicine’s family medicine Special Interest Group (SIG) Executive Committee and Faculty Director of Inpatient Services at UPMC McKeesport (Pa.) Family Medicine Residency, said hearsay inside the family medicine community influenced her first job search looking for hospitalist positions as a family medicine physician.

Experience, education closes some gaps

Over the years, the American Board of Family Medicine (ABFM) and SHM have offered several opportunities for family medicine doctors to demonstrate their experience and training in hospital medicine. In 2010, ABFM began offering the Focused Recognition of Hospital Medicine board examination, together with the American Board of Internal Medicine. SHM also offers hospitalist fellowships and a designation of Fellow in Hospital Medicine (FHM) for health care professionals. In 2015, ABFM and SHM released a joint statement encouraging the growth of hospitalists trained in family medicine (HTFM) and outlining these opportunities.
These measures help fill a gap in both IM and FM training, but also appear to have some effect in convincing recruiters and employers to consider family medicine doctors for hospitalist positions. An abstract published at Hospital Medicine 2014 reviewed 252 hospitalist positions listed in journals and search engines attempted to document the disparities in job listings, the perceptions of physician recruiters, and how factors like experience, training, and certification impacted a family medicine physician’s likelihood to be considered for a position. HTFMs were explicitly mentioned as being eligible in 119 of 252 positions (47%). The investigators then sent surveys out to physician recruiters of the remaining 133 positions asking whether HTFMs were being considered for the position. The results of the survey showed 66% of the recruiters were open to HTFMs, while 34% of recruiters said they did not have a willingness to hire HTFMs. 
That willingness to hire changed based on the level of experience, training, and certification. More than one-fourth (29%) of physician recruiters said institutional bylaws prevented hiring of HTFMs. If respondents earned a Recognition of Focused Practice in Hospital Medicine (RFPHM) board examination, 78% of physician recruiters would reconsider hiring the candidate. If the HTFM applicant had prior experience in hospital medicine, 87% of physician recruiters said they would consider the candidate. HTFMs who earned a Designation of Fellow in Hospital Medicine (FHM) from SHM would be reconsidered by 93% of physician recruiters who initially refused the HTFM candidate. All physician recruiters said they would reconsider if the candidate had a fellowship in hospital medicine.
However, to date, there is no official American College of Graduate Medical Education (ACGME)-recognized hospitalist board certification or designated specialty credentialing. This can lead to situations where family medicine trained physicians are applying for jobs without the necessary requirements for the position, because those requirements may not be immediately obvious when first applying to a position. “There’s often no specification until you apply and then are informed that you don’t qualify – ‘Oh, no, you  haven’t completed a fellowship,’ or the added qualification in hospital medicine,” Dr. McCurry said.
The 2015 joint statement from AAFP and SHM asserts that “more than two-thirds of HTFMs are also involved in the training of residents and medical students, enhancing the skills of our future physicians.” But when HTFMs do find positions, they may be limited in other ways, such as being prohibited from serving on the faculty of internal medicine residency programs and teaching internal medicine residents. When Dr. Odeti was medical director for Johnston Memorial Hospital in Abingdon, Va., he said he encountered this issue.
“If you are a hospitalist who is internal medicine trained, then you can teach FM or IM, whereas if you’re family medicine trained, you cannot teach internal medicine residents,” he said. “What happened with me, I had to prioritize recruiting internal medicine residents over FM residents to be able to staff IM teaching faculty.”
A rule change has been lobbied by SHM, under the direction of SHM family medicine SIG former chair David Goldstein, MD, to address this issue that would allow HTFMs with a FPHM designation to teach IM residents. The change was quietly made by the ACGME Review Committee for Internal Medicine in 2017, Dr. McCurry said, but implementation of the change has been slow.
“Essentially, the change was made in 2017 to allow for family medicine trainied physicians who have the FPHM designation to teach IM residents, but this knowledge has not been widely dispersed or policies updated to clearly reflect this change,” Dr. McCurry said. “It is a significant change, however, because prior to that, there were explicit policies preventing a family medicine hospitalist from teaching internal medicine residents even if they were experienced.”

FM physicians uniquely suited for HM

Requirements aside, it is “arguably not the case” that family medicine physicians need these extra certifications and fellowships to serve as hospitalists, Dr. McCurry said. It is difficult to quantify IM and FM hospitalist quality outcomes due to challenges with attribution, Dr. Odeti noted. One 2007 study published in the New England Journal of Medicine looked at patient quality and cost of care across the hospitalist model, and family medicine practitioners providing inpatients care. The investigators found similar outcomes in the internist model and with family practitioners providing inpatient care. Dr. Odeti said this research supports “the fact that family medicine physicians are equally competent as internists in providing inpatient care.”

HTFMs are growing within SHM

HTFMs are “all over,” being represented in smaller hospitals, larger hospitals, and university hospitals in every state. “But to reach those positions, they probably have to go over more hurdles and have fewer opportunities,” Dr. Chaudhry said.
There isn’t a completely accurate count of family medicine hospitalists in the United States. Out of an estimated 50,000 hospitalists in the U. S., about 16,000 hospitalists are members of SHM. A number of family medicine hospitalists may also take AAFP membership instead of SHM, Dr. Odeti explained.
However, there are a growing number of hospitalists within SHM with a family medicine background. In the 2007-2008 Society of Hospital Medicine Annual Survey, 3.7% of U.S. hospitalists claimed family medicine training. That number increased to 6.9% of physicians who answered the SHM membership data report in 2010.
A Medscape Hospitalist Lifestyle, Happiness & Burnout Report from 2019 estimates 17% of hospitalists are trained in family medicine. In the latest State of Hospital Medicine Report published in 2020, 38.6% of hospital medicine groups containing family medicine trained physicians were part of a university, medical school, or faculty practice; 79.6% did not have academic status; 83.8% were at a non-teaching hospital; 60.7% were in a group in a non-teaching service at a teaching hospital; and 52.8% were in a group at a combination teaching/non-teaching service at a teaching hospital.
Although the Report did not specify whether family medicine hospitalists were mainly in rural or urban areas, “some of us do practice in underserved area hospitals where you have the smaller ICU model, critical access hospitals, potentially dealing with a whole gamut of inpatient medicine from ER, to the hospital inpatient adult cases, to critical care level,” Dr. McCurry said. 
“But then, there are a large number of us who practice in private groups or at large hospitals, academic centers around the country,” she added. “There’s a range of family medicine trained hospitalist practice areas.”

Equal recognition for HTFM in HM

The SHM family medicine SIG has been working to highlight the issue of hiring practices for HTFMs, and is taking a number of actions to bring greater awareness and recognition to family medicine hospitalists.
The family medicine SIG is looking at steps for requesting a new joint statement from ABFM and SHM focused on hiring practices for family medicine physicians as hospitalists. “I think it’s worth considering now that we’re at a point where we comprise about one-fifth of hospitalists as family medicine docs,” Dr. McCurry said. “Is it time to take that joint statement to the next step, and seek a review of how we can improve the balance of hiring in terms of favoring more balanced consideration now that there are a lot more family medicine trained hospitalists than historically?
“I think the call is really to help us all move to that next step in terms of identifying any of the lingering vestiges of expectation that are really no longer applicable to the hiring practices, or shouldn’t be,” she said. 
The next step will be to ask hospitals with internal medicine only requirements for hospitalists to update their bylaws to include family medicine physicians when considering candidates for hospitalist positions. If SHM does not make a distinction to grant Fellow in Hospital Medicine status between internal medicine and family medicine trained hospitalists, “then there should not be any distinction, or there should not be any hindrance by the recruiters, by the bigger systems, as well as by the employers” in hiring a family medicine trained physician for a hospitalist position, Dr. Chaudhry said.
Dr. Odeti, who serves in several leadership roles within Ballad Health, describes the system as being friendly to HTFMs. About one-fourth of the hospitalists in Ballad Health are trained in family medicine. But when Dr. Odeti started his hospitalist practice, he was only one of a handful of HTFMs. He sees a future where the accomplishments and contributions of HTFMs will pave the way for future hospitalists. “Access into the urban hospitals is key, and I hope that SHM and the HTFM SIG will act as a catalyst for this change,” he said.
Colleagues of family medicine hospitalists, especially those in leadership positions at hospitals, can help by raising awareness, as can “those of our colleagues who sit on medical executive committees within their hospitals to review their bylaws, to see what the policies are, and encourage more competitiveness,” Dr. McCurry said. “Truly, the best candidate for the position, regardless of background and training, is what you want. You want the best colleagues for your fellow hospitalists. You want the best physician for your patients in the hospital.”
If training and all other things are equal, family medicine physicians should be evaluated on a case-by-case basis, she said. “I think that that puts the burden back on any good medical committee, and a good medical committee member who is an SHM member as well, to say, ‘If we are committed to quality patient care, we want to encourage the recruitment of all physicians that are truly the best physicians to reduce that distinction between FM and IM in order to allow those best candidates to present, whether they are FM or IM.’ That’s all that we’re asking.”
Dr. Chaudhry emphasized that the preference for internal medicine trained physicians isn’t intentional. “It’s not as if the systems are trying to do it,” he said. “I think it is more like everybody needs to be educated. And through the platform of the Society of Hospital Medicine, I think we can make a difference. It will be a slow change, but we’ll have to keep on working on it.”

Dr. Odeti, Dr. McCurry, and Dr. Chaudhry have no relevant financial disclosures.
 

A family medicine trained doctor, fresh out of residency, visits a career website to scout out prospective hospitalist jobs in their region. As they scroll through the job listings, they come across one opportunity at a nearby hospital system that seems like a good fit. The listing offers a competitive salary and comprehensive benefits for the position, and mentions hospitalists in the department will have the opportunity to teach medical students.

The only problem? The position is for internal medicine trained doctors only. After searching through several more listings with the same internal medicine requirement, the pool of jobs available to the family medicine doctor seems much smaller.
When Robert M. Wachter, MD, MHM, and Lee Goldman, MD coined the term “hospitalist” in a 1996 New England Journal of Medicine article, hospitalists were primarily clinicians with an internal medicine background, filling the gap created by family medicine doctors who increasingly devoted their time to patients in their practice and spent less time rounding in the hospital.
As family medicine doctors have returned to hospital medicine, it has become difficult to find positions as hospitalists due to a preference by some recruiters and employers that favors internal medicine physicians over those who are trained in family medicine. The preference for internal medicine physicians is sometimes overt, such as a requirement on a job application. But the preference can also surface after a physician has already applied for a position, and they will then discover a recruiter is actually looking for someone with a background in internal medicine. In other cases, family medicine physicians find out after applying that applicants with a background in family medicine are considered, but they’re expected to have additional training or certification not listed on the job application. 
The situation can even be as stark as a hospital system hiring an internal medicine doctor just out of residency over a family medicine doctor with years of experience as a board-certified physician. Hiring practices in large systems across multiple states sometimes don’t just favor internal medicine, they are entirely focused on internal medicine hospitalists, said experts who spoke with The Hospitalist.

Outdated perceptions of family medicine

Victoria McCurry, MD, current chair of the Society of Hospital Medicine’s family medicine Special Interest Group (SIG) Executive Committee and Faculty Director of Inpatient Services at UPMC McKeesport (Pa.) Family Medicine Residency, said hearsay inside the family medicine community influenced her first job search looking for hospitalist positions as a family medicine physician.

Experience, education closes some gaps

Over the years, the American Board of Family Medicine (ABFM) and SHM have offered several opportunities for family medicine doctors to demonstrate their experience and training in hospital medicine. In 2010, ABFM began offering the Focused Recognition of Hospital Medicine board examination, together with the American Board of Internal Medicine. SHM also offers hospitalist fellowships and a designation of Fellow in Hospital Medicine (FHM) for health care professionals. In 2015, ABFM and SHM released a joint statement encouraging the growth of hospitalists trained in family medicine (HTFM) and outlining these opportunities.
These measures help fill a gap in both IM and FM training, but also appear to have some effect in convincing recruiters and employers to consider family medicine doctors for hospitalist positions. An abstract published at Hospital Medicine 2014 reviewed 252 hospitalist positions listed in journals and search engines attempted to document the disparities in job listings, the perceptions of physician recruiters, and how factors like experience, training, and certification impacted a family medicine physician’s likelihood to be considered for a position. HTFMs were explicitly mentioned as being eligible in 119 of 252 positions (47%). The investigators then sent surveys out to physician recruiters of the remaining 133 positions asking whether HTFMs were being considered for the position. The results of the survey showed 66% of the recruiters were open to HTFMs, while 34% of recruiters said they did not have a willingness to hire HTFMs. 
That willingness to hire changed based on the level of experience, training, and certification. More than one-fourth (29%) of physician recruiters said institutional bylaws prevented hiring of HTFMs. If respondents earned a Recognition of Focused Practice in Hospital Medicine (RFPHM) board examination, 78% of physician recruiters would reconsider hiring the candidate. If the HTFM applicant had prior experience in hospital medicine, 87% of physician recruiters said they would consider the candidate. HTFMs who earned a Designation of Fellow in Hospital Medicine (FHM) from SHM would be reconsidered by 93% of physician recruiters who initially refused the HTFM candidate. All physician recruiters said they would reconsider if the candidate had a fellowship in hospital medicine.
However, to date, there is no official American College of Graduate Medical Education (ACGME)-recognized hospitalist board certification or designated specialty credentialing. This can lead to situations where family medicine trained physicians are applying for jobs without the necessary requirements for the position, because those requirements may not be immediately obvious when first applying to a position. “There’s often no specification until you apply and then are informed that you don’t qualify – ‘Oh, no, you  haven’t completed a fellowship,’ or the added qualification in hospital medicine,” Dr. McCurry said.
The 2015 joint statement from AAFP and SHM asserts that “more than two-thirds of HTFMs are also involved in the training of residents and medical students, enhancing the skills of our future physicians.” But when HTFMs do find positions, they may be limited in other ways, such as being prohibited from serving on the faculty of internal medicine residency programs and teaching internal medicine residents. When Dr. Odeti was medical director for Johnston Memorial Hospital in Abingdon, Va., he said he encountered this issue.
“If you are a hospitalist who is internal medicine trained, then you can teach FM or IM, whereas if you’re family medicine trained, you cannot teach internal medicine residents,” he said. “What happened with me, I had to prioritize recruiting internal medicine residents over FM residents to be able to staff IM teaching faculty.”
A rule change has been lobbied by SHM, under the direction of SHM family medicine SIG former chair David Goldstein, MD, to address this issue that would allow HTFMs with a FPHM designation to teach IM residents. The change was quietly made by the ACGME Review Committee for Internal Medicine in 2017, Dr. McCurry said, but implementation of the change has been slow.
“Essentially, the change was made in 2017 to allow for family medicine trainied physicians who have the FPHM designation to teach IM residents, but this knowledge has not been widely dispersed or policies updated to clearly reflect this change,” Dr. McCurry said. “It is a significant change, however, because prior to that, there were explicit policies preventing a family medicine hospitalist from teaching internal medicine residents even if they were experienced.”

FM physicians uniquely suited for HM

Requirements aside, it is “arguably not the case” that family medicine physicians need these extra certifications and fellowships to serve as hospitalists, Dr. McCurry said. It is difficult to quantify IM and FM hospitalist quality outcomes due to challenges with attribution, Dr. Odeti noted. One 2007 study published in the New England Journal of Medicine looked at patient quality and cost of care across the hospitalist model, and family medicine practitioners providing inpatients care. The investigators found similar outcomes in the internist model and with family practitioners providing inpatient care. Dr. Odeti said this research supports “the fact that family medicine physicians are equally competent as internists in providing inpatient care.”

HTFMs are growing within SHM

HTFMs are “all over,” being represented in smaller hospitals, larger hospitals, and university hospitals in every state. “But to reach those positions, they probably have to go over more hurdles and have fewer opportunities,” Dr. Chaudhry said.
There isn’t a completely accurate count of family medicine hospitalists in the United States. Out of an estimated 50,000 hospitalists in the U. S., about 16,000 hospitalists are members of SHM. A number of family medicine hospitalists may also take AAFP membership instead of SHM, Dr. Odeti explained.
However, there are a growing number of hospitalists within SHM with a family medicine background. In the 2007-2008 Society of Hospital Medicine Annual Survey, 3.7% of U.S. hospitalists claimed family medicine training. That number increased to 6.9% of physicians who answered the SHM membership data report in 2010.
A Medscape Hospitalist Lifestyle, Happiness & Burnout Report from 2019 estimates 17% of hospitalists are trained in family medicine. In the latest State of Hospital Medicine Report published in 2020, 38.6% of hospital medicine groups containing family medicine trained physicians were part of a university, medical school, or faculty practice; 79.6% did not have academic status; 83.8% were at a non-teaching hospital; 60.7% were in a group in a non-teaching service at a teaching hospital; and 52.8% were in a group at a combination teaching/non-teaching service at a teaching hospital.
Although the Report did not specify whether family medicine hospitalists were mainly in rural or urban areas, “some of us do practice in underserved area hospitals where you have the smaller ICU model, critical access hospitals, potentially dealing with a whole gamut of inpatient medicine from ER, to the hospital inpatient adult cases, to critical care level,” Dr. McCurry said. 
“But then, there are a large number of us who practice in private groups or at large hospitals, academic centers around the country,” she added. “There’s a range of family medicine trained hospitalist practice areas.”

Equal recognition for HTFM in HM

The SHM family medicine SIG has been working to highlight the issue of hiring practices for HTFMs, and is taking a number of actions to bring greater awareness and recognition to family medicine hospitalists.
The family medicine SIG is looking at steps for requesting a new joint statement from ABFM and SHM focused on hiring practices for family medicine physicians as hospitalists. “I think it’s worth considering now that we’re at a point where we comprise about one-fifth of hospitalists as family medicine docs,” Dr. McCurry said. “Is it time to take that joint statement to the next step, and seek a review of how we can improve the balance of hiring in terms of favoring more balanced consideration now that there are a lot more family medicine trained hospitalists than historically?
“I think the call is really to help us all move to that next step in terms of identifying any of the lingering vestiges of expectation that are really no longer applicable to the hiring practices, or shouldn’t be,” she said. 
The next step will be to ask hospitals with internal medicine only requirements for hospitalists to update their bylaws to include family medicine physicians when considering candidates for hospitalist positions. If SHM does not make a distinction to grant Fellow in Hospital Medicine status between internal medicine and family medicine trained hospitalists, “then there should not be any distinction, or there should not be any hindrance by the recruiters, by the bigger systems, as well as by the employers” in hiring a family medicine trained physician for a hospitalist position, Dr. Chaudhry said.
Dr. Odeti, who serves in several leadership roles within Ballad Health, describes the system as being friendly to HTFMs. About one-fourth of the hospitalists in Ballad Health are trained in family medicine. But when Dr. Odeti started his hospitalist practice, he was only one of a handful of HTFMs. He sees a future where the accomplishments and contributions of HTFMs will pave the way for future hospitalists. “Access into the urban hospitals is key, and I hope that SHM and the HTFM SIG will act as a catalyst for this change,” he said.
Colleagues of family medicine hospitalists, especially those in leadership positions at hospitals, can help by raising awareness, as can “those of our colleagues who sit on medical executive committees within their hospitals to review their bylaws, to see what the policies are, and encourage more competitiveness,” Dr. McCurry said. “Truly, the best candidate for the position, regardless of background and training, is what you want. You want the best colleagues for your fellow hospitalists. You want the best physician for your patients in the hospital.”
If training and all other things are equal, family medicine physicians should be evaluated on a case-by-case basis, she said. “I think that that puts the burden back on any good medical committee, and a good medical committee member who is an SHM member as well, to say, ‘If we are committed to quality patient care, we want to encourage the recruitment of all physicians that are truly the best physicians to reduce that distinction between FM and IM in order to allow those best candidates to present, whether they are FM or IM.’ That’s all that we’re asking.”
Dr. Chaudhry emphasized that the preference for internal medicine trained physicians isn’t intentional. “It’s not as if the systems are trying to do it,” he said. “I think it is more like everybody needs to be educated. And through the platform of the Society of Hospital Medicine, I think we can make a difference. It will be a slow change, but we’ll have to keep on working on it.”

Dr. Odeti, Dr. McCurry, and Dr. Chaudhry have no relevant financial disclosures.
 

A family medicine trained doctor, fresh out of residency, visits a career website to scout out prospective hospitalist jobs in their region. As they scroll through the job listings, they come across one opportunity at a nearby hospital system that seems like a good fit. The listing offers a competitive salary and comprehensive benefits for the position, and mentions hospitalists in the department will have the opportunity to teach medical students.

The only problem? The position is for internal medicine trained doctors only. After searching through several more listings with the same internal medicine requirement, the pool of jobs available to the family medicine doctor seems much smaller.
When Robert M. Wachter, MD, MHM, and Lee Goldman, MD coined the term “hospitalist” in a 1996 New England Journal of Medicine article, hospitalists were primarily clinicians with an internal medicine background, filling the gap created by family medicine doctors who increasingly devoted their time to patients in their practice and spent less time rounding in the hospital.
As family medicine doctors have returned to hospital medicine, it has become difficult to find positions as hospitalists due to a preference by some recruiters and employers that favors internal medicine physicians over those who are trained in family medicine. The preference for internal medicine physicians is sometimes overt, such as a requirement on a job application. But the preference can also surface after a physician has already applied for a position, and they will then discover a recruiter is actually looking for someone with a background in internal medicine. In other cases, family medicine physicians find out after applying that applicants with a background in family medicine are considered, but they’re expected to have additional training or certification not listed on the job application. 
The situation can even be as stark as a hospital system hiring an internal medicine doctor just out of residency over a family medicine doctor with years of experience as a board-certified physician. Hiring practices in large systems across multiple states sometimes don’t just favor internal medicine, they are entirely focused on internal medicine hospitalists, said experts who spoke with The Hospitalist.

Outdated perceptions of family medicine

Victoria McCurry, MD, current chair of the Society of Hospital Medicine’s family medicine Special Interest Group (SIG) Executive Committee and Faculty Director of Inpatient Services at UPMC McKeesport (Pa.) Family Medicine Residency, said hearsay inside the family medicine community influenced her first job search looking for hospitalist positions as a family medicine physician.

Experience, education closes some gaps

Over the years, the American Board of Family Medicine (ABFM) and SHM have offered several opportunities for family medicine doctors to demonstrate their experience and training in hospital medicine. In 2010, ABFM began offering the Focused Recognition of Hospital Medicine board examination, together with the American Board of Internal Medicine. SHM also offers hospitalist fellowships and a designation of Fellow in Hospital Medicine (FHM) for health care professionals. In 2015, ABFM and SHM released a joint statement encouraging the growth of hospitalists trained in family medicine (HTFM) and outlining these opportunities.
These measures help fill a gap in both IM and FM training, but also appear to have some effect in convincing recruiters and employers to consider family medicine doctors for hospitalist positions. An abstract published at Hospital Medicine 2014 reviewed 252 hospitalist positions listed in journals and search engines attempted to document the disparities in job listings, the perceptions of physician recruiters, and how factors like experience, training, and certification impacted a family medicine physician’s likelihood to be considered for a position. HTFMs were explicitly mentioned as being eligible in 119 of 252 positions (47%). The investigators then sent surveys out to physician recruiters of the remaining 133 positions asking whether HTFMs were being considered for the position. The results of the survey showed 66% of the recruiters were open to HTFMs, while 34% of recruiters said they did not have a willingness to hire HTFMs. 
That willingness to hire changed based on the level of experience, training, and certification. More than one-fourth (29%) of physician recruiters said institutional bylaws prevented hiring of HTFMs. If respondents earned a Recognition of Focused Practice in Hospital Medicine (RFPHM) board examination, 78% of physician recruiters would reconsider hiring the candidate. If the HTFM applicant had prior experience in hospital medicine, 87% of physician recruiters said they would consider the candidate. HTFMs who earned a Designation of Fellow in Hospital Medicine (FHM) from SHM would be reconsidered by 93% of physician recruiters who initially refused the HTFM candidate. All physician recruiters said they would reconsider if the candidate had a fellowship in hospital medicine.
However, to date, there is no official American College of Graduate Medical Education (ACGME)-recognized hospitalist board certification or designated specialty credentialing. This can lead to situations where family medicine trained physicians are applying for jobs without the necessary requirements for the position, because those requirements may not be immediately obvious when first applying to a position. “There’s often no specification until you apply and then are informed that you don’t qualify – ‘Oh, no, you  haven’t completed a fellowship,’ or the added qualification in hospital medicine,” Dr. McCurry said.
The 2015 joint statement from AAFP and SHM asserts that “more than two-thirds of HTFMs are also involved in the training of residents and medical students, enhancing the skills of our future physicians.” But when HTFMs do find positions, they may be limited in other ways, such as being prohibited from serving on the faculty of internal medicine residency programs and teaching internal medicine residents. When Dr. Odeti was medical director for Johnston Memorial Hospital in Abingdon, Va., he said he encountered this issue.
“If you are a hospitalist who is internal medicine trained, then you can teach FM or IM, whereas if you’re family medicine trained, you cannot teach internal medicine residents,” he said. “What happened with me, I had to prioritize recruiting internal medicine residents over FM residents to be able to staff IM teaching faculty.”
A rule change has been lobbied by SHM, under the direction of SHM family medicine SIG former chair David Goldstein, MD, to address this issue that would allow HTFMs with a FPHM designation to teach IM residents. The change was quietly made by the ACGME Review Committee for Internal Medicine in 2017, Dr. McCurry said, but implementation of the change has been slow.
“Essentially, the change was made in 2017 to allow for family medicine trainied physicians who have the FPHM designation to teach IM residents, but this knowledge has not been widely dispersed or policies updated to clearly reflect this change,” Dr. McCurry said. “It is a significant change, however, because prior to that, there were explicit policies preventing a family medicine hospitalist from teaching internal medicine residents even if they were experienced.”

FM physicians uniquely suited for HM

Requirements aside, it is “arguably not the case” that family medicine physicians need these extra certifications and fellowships to serve as hospitalists, Dr. McCurry said. It is difficult to quantify IM and FM hospitalist quality outcomes due to challenges with attribution, Dr. Odeti noted. One 2007 study published in the New England Journal of Medicine looked at patient quality and cost of care across the hospitalist model, and family medicine practitioners providing inpatients care. The investigators found similar outcomes in the internist model and with family practitioners providing inpatient care. Dr. Odeti said this research supports “the fact that family medicine physicians are equally competent as internists in providing inpatient care.”

HTFMs are growing within SHM

HTFMs are “all over,” being represented in smaller hospitals, larger hospitals, and university hospitals in every state. “But to reach those positions, they probably have to go over more hurdles and have fewer opportunities,” Dr. Chaudhry said.
There isn’t a completely accurate count of family medicine hospitalists in the United States. Out of an estimated 50,000 hospitalists in the U. S., about 16,000 hospitalists are members of SHM. A number of family medicine hospitalists may also take AAFP membership instead of SHM, Dr. Odeti explained.
However, there are a growing number of hospitalists within SHM with a family medicine background. In the 2007-2008 Society of Hospital Medicine Annual Survey, 3.7% of U.S. hospitalists claimed family medicine training. That number increased to 6.9% of physicians who answered the SHM membership data report in 2010.
A Medscape Hospitalist Lifestyle, Happiness & Burnout Report from 2019 estimates 17% of hospitalists are trained in family medicine. In the latest State of Hospital Medicine Report published in 2020, 38.6% of hospital medicine groups containing family medicine trained physicians were part of a university, medical school, or faculty practice; 79.6% did not have academic status; 83.8% were at a non-teaching hospital; 60.7% were in a group in a non-teaching service at a teaching hospital; and 52.8% were in a group at a combination teaching/non-teaching service at a teaching hospital.
Although the Report did not specify whether family medicine hospitalists were mainly in rural or urban areas, “some of us do practice in underserved area hospitals where you have the smaller ICU model, critical access hospitals, potentially dealing with a whole gamut of inpatient medicine from ER, to the hospital inpatient adult cases, to critical care level,” Dr. McCurry said. 
“But then, there are a large number of us who practice in private groups or at large hospitals, academic centers around the country,” she added. “There’s a range of family medicine trained hospitalist practice areas.”

Equal recognition for HTFM in HM

The SHM family medicine SIG has been working to highlight the issue of hiring practices for HTFMs, and is taking a number of actions to bring greater awareness and recognition to family medicine hospitalists.
The family medicine SIG is looking at steps for requesting a new joint statement from ABFM and SHM focused on hiring practices for family medicine physicians as hospitalists. “I think it’s worth considering now that we’re at a point where we comprise about one-fifth of hospitalists as family medicine docs,” Dr. McCurry said. “Is it time to take that joint statement to the next step, and seek a review of how we can improve the balance of hiring in terms of favoring more balanced consideration now that there are a lot more family medicine trained hospitalists than historically?
“I think the call is really to help us all move to that next step in terms of identifying any of the lingering vestiges of expectation that are really no longer applicable to the hiring practices, or shouldn’t be,” she said. 
The next step will be to ask hospitals with internal medicine only requirements for hospitalists to update their bylaws to include family medicine physicians when considering candidates for hospitalist positions. If SHM does not make a distinction to grant Fellow in Hospital Medicine status between internal medicine and family medicine trained hospitalists, “then there should not be any distinction, or there should not be any hindrance by the recruiters, by the bigger systems, as well as by the employers” in hiring a family medicine trained physician for a hospitalist position, Dr. Chaudhry said.
Dr. Odeti, who serves in several leadership roles within Ballad Health, describes the system as being friendly to HTFMs. About one-fourth of the hospitalists in Ballad Health are trained in family medicine. But when Dr. Odeti started his hospitalist practice, he was only one of a handful of HTFMs. He sees a future where the accomplishments and contributions of HTFMs will pave the way for future hospitalists. “Access into the urban hospitals is key, and I hope that SHM and the HTFM SIG will act as a catalyst for this change,” he said.
Colleagues of family medicine hospitalists, especially those in leadership positions at hospitals, can help by raising awareness, as can “those of our colleagues who sit on medical executive committees within their hospitals to review their bylaws, to see what the policies are, and encourage more competitiveness,” Dr. McCurry said. “Truly, the best candidate for the position, regardless of background and training, is what you want. You want the best colleagues for your fellow hospitalists. You want the best physician for your patients in the hospital.”
If training and all other things are equal, family medicine physicians should be evaluated on a case-by-case basis, she said. “I think that that puts the burden back on any good medical committee, and a good medical committee member who is an SHM member as well, to say, ‘If we are committed to quality patient care, we want to encourage the recruitment of all physicians that are truly the best physicians to reduce that distinction between FM and IM in order to allow those best candidates to present, whether they are FM or IM.’ That’s all that we’re asking.”
Dr. Chaudhry emphasized that the preference for internal medicine trained physicians isn’t intentional. “It’s not as if the systems are trying to do it,” he said. “I think it is more like everybody needs to be educated. And through the platform of the Society of Hospital Medicine, I think we can make a difference. It will be a slow change, but we’ll have to keep on working on it.”

Dr. Odeti, Dr. McCurry, and Dr. Chaudhry have no relevant financial disclosures.
 

How quickly things change. On September 23, 2019 – months before the COVID-19 pandemic struck – at a UN High-Level Meeting on Universal Health Coverage, heads of state from around the world pledged to achieve universal health coverage by 2030.

“This will be an unprecedented moment in public health: according to the declaration being negotiated by member states, this commitment is being made globally ‘for the first time.’ Whether or not the new commitment succeeds will depend on a large degree of advocacy at the national level.”
 

Reference

1. Carter M, Emmel A. The Global Community Has Pledged To Achieve Universal Health Coverage: What’s It Going To Take? Health Affairs Blog, 2019 Sept 23. doi: 10.1377/hblog20190920.827005.

How quickly things change. On September 23, 2019 – months before the COVID-19 pandemic struck – at a UN High-Level Meeting on Universal Health Coverage, heads of state from around the world pledged to achieve universal health coverage by 2030.

“This will be an unprecedented moment in public health: according to the declaration being negotiated by member states, this commitment is being made globally ‘for the first time.’ Whether or not the new commitment succeeds will depend on a large degree of advocacy at the national level.”
 

Reference

1. Carter M, Emmel A. The Global Community Has Pledged To Achieve Universal Health Coverage: What’s It Going To Take? Health Affairs Blog, 2019 Sept 23. doi: 10.1377/hblog20190920.827005.

How quickly things change. On September 23, 2019 – months before the COVID-19 pandemic struck – at a UN High-Level Meeting on Universal Health Coverage, heads of state from around the world pledged to achieve universal health coverage by 2030.

“This will be an unprecedented moment in public health: according to the declaration being negotiated by member states, this commitment is being made globally ‘for the first time.’ Whether or not the new commitment succeeds will depend on a large degree of advocacy at the national level.”
 

Reference

1. Carter M, Emmel A. The Global Community Has Pledged To Achieve Universal Health Coverage: What’s It Going To Take? Health Affairs Blog, 2019 Sept 23. doi: 10.1377/hblog20190920.827005.

Hospitalists and health care teams struggle with issues related to text messaging in the workplace. “It’s happening whether an institution has a secure text messaging platform or not,” said Philip Hagedorn, MD, MBI, associate chief medical information officer at Cincinnati Children’s Hospital Medical Center.

“Many places reacted to this reality by procuring a solution – take your pick of secure text messaging platforms – and implementing it, but bypassed an opportunity to think about how we tailor the use of this culturally ubiquitous medium to the health care setting,” he said.It doesn’t work to just drop a secure text messaging platform into clinical systems and expect that health care practitioners will know how to use them appropriately, Dr. Hagedorn says. “The way we use text messaging in our lives outside health care inevitably bleeds into how we use the medium at work, but it shouldn’t. The needs are different and the stakes are higher for communication in the health care setting.”

In a paper looking at the issue, Dr. Hagedorn and co-authors laid out critical areas of concern, such as text messaging becoming a form of alarm fatigue and also increasing the likelihood of communication error.

“It’s my hope that fellow hospitalists can use this as an opportunity to think deeply about how we communicate in health care,” he said. “If we don’t think critically about how and where something like text messaging should be used in medicine, we risk facing unintended consequences for our patients.”The article discusses several steps for mitigating the risks laid out, including proactive surveillance and targeted training. “These are starting points, and I’m sure there are plenty of other creative solutions out there. We wanted to get the conversation going. We’d love to hear from others who face similar issues or have come up with interesting solutions.”
 

Reference

1. Hagedorn PA, et al. Secure Text Messaging in Healthcare: Latent Threats and Opportunities to Improve Patient Safety. J Hosp Med. 2020 June;15(6):378-380. Published Online First 2019 Sept 18. doi: 10.12788/jhm.3305

Hospitalists and health care teams struggle with issues related to text messaging in the workplace. “It’s happening whether an institution has a secure text messaging platform or not,” said Philip Hagedorn, MD, MBI, associate chief medical information officer at Cincinnati Children’s Hospital Medical Center.

“Many places reacted to this reality by procuring a solution – take your pick of secure text messaging platforms – and implementing it, but bypassed an opportunity to think about how we tailor the use of this culturally ubiquitous medium to the health care setting,” he said.It doesn’t work to just drop a secure text messaging platform into clinical systems and expect that health care practitioners will know how to use them appropriately, Dr. Hagedorn says. “The way we use text messaging in our lives outside health care inevitably bleeds into how we use the medium at work, but it shouldn’t. The needs are different and the stakes are higher for communication in the health care setting.”

In a paper looking at the issue, Dr. Hagedorn and co-authors laid out critical areas of concern, such as text messaging becoming a form of alarm fatigue and also increasing the likelihood of communication error.

“It’s my hope that fellow hospitalists can use this as an opportunity to think deeply about how we communicate in health care,” he said. “If we don’t think critically about how and where something like text messaging should be used in medicine, we risk facing unintended consequences for our patients.”The article discusses several steps for mitigating the risks laid out, including proactive surveillance and targeted training. “These are starting points, and I’m sure there are plenty of other creative solutions out there. We wanted to get the conversation going. We’d love to hear from others who face similar issues or have come up with interesting solutions.”
 

Reference

1. Hagedorn PA, et al. Secure Text Messaging in Healthcare: Latent Threats and Opportunities to Improve Patient Safety. J Hosp Med. 2020 June;15(6):378-380. Published Online First 2019 Sept 18. doi: 10.12788/jhm.3305

Hospitalists and health care teams struggle with issues related to text messaging in the workplace. “It’s happening whether an institution has a secure text messaging platform or not,” said Philip Hagedorn, MD, MBI, associate chief medical information officer at Cincinnati Children’s Hospital Medical Center.

“Many places reacted to this reality by procuring a solution – take your pick of secure text messaging platforms – and implementing it, but bypassed an opportunity to think about how we tailor the use of this culturally ubiquitous medium to the health care setting,” he said.It doesn’t work to just drop a secure text messaging platform into clinical systems and expect that health care practitioners will know how to use them appropriately, Dr. Hagedorn says. “The way we use text messaging in our lives outside health care inevitably bleeds into how we use the medium at work, but it shouldn’t. The needs are different and the stakes are higher for communication in the health care setting.”

In a paper looking at the issue, Dr. Hagedorn and co-authors laid out critical areas of concern, such as text messaging becoming a form of alarm fatigue and also increasing the likelihood of communication error.

“It’s my hope that fellow hospitalists can use this as an opportunity to think deeply about how we communicate in health care,” he said. “If we don’t think critically about how and where something like text messaging should be used in medicine, we risk facing unintended consequences for our patients.”The article discusses several steps for mitigating the risks laid out, including proactive surveillance and targeted training. “These are starting points, and I’m sure there are plenty of other creative solutions out there. We wanted to get the conversation going. We’d love to hear from others who face similar issues or have come up with interesting solutions.”
 

Reference

1. Hagedorn PA, et al. Secure Text Messaging in Healthcare: Latent Threats and Opportunities to Improve Patient Safety. J Hosp Med. 2020 June;15(6):378-380. Published Online First 2019 Sept 18. doi: 10.12788/jhm.3305

Hospitalists in the VA system see patients with symptoms of alcohol withdrawal frequently – there are about 33,000 hospital admissions each year for alcohol withdrawal syndrome (AWS), says Robert Patrick, MD, of the Louis Stokes Cleveland VA Medical Center.

“By contrast, the number of admissions for the largest ambulatory care sensitive condition (heart failure) is only about 28,000,” he said. “If alcohol detox were an ambulatory care sensitive condition, it would be the largest in the VA by a substantial margin.”The purpose of the project he and his co-author, Laura Brown, MD, created to address the problem was to increase the number of patients treated for AWS as outpatients and decrease hospital admissions – without increasing readmissions or clinical deterioration.

They introduced four core operational changes for their study:

1. Standardized risk stratification in the Emergency Department (ED) to identify low risk patients for outpatient treatment.

2. Benzodiazepine sparing symptom triggered medication regimen.

3. Daily clinical dashboard surveillance and risk stratification for continued hospital stay.

4. Telephone follow-up for patients discharged from the ED or hospital.

With these changes in place, eight months of data showed a 50% reduction in AWS admissions and a 40% reduction in length of stays.

Their conclusion? “A well designed and executed QI project can dramatically reduce hospitalist workload, while at the same time improving patient safety,” Dr. Patrick said. “Hospitalists just have to be willing to think outside the box, work with nursing and coordinate care outside of the hospital to make it happen.”

He added a caveat for hospital medicine groups still in a fee-for-service environment. “This saves money for the payer, not the hospital,” he said. “In our case they are one and the same, so the ROI is huge. If you are part of an ACO this is probably true for you, but I would check with your ACO first.”
 

Reference

1. Patrick RM, Brown LZ. Decreasing Admissions, Readmissions and Length of Stay While Improving Patent Safety for Alcohol Withdrawal Syndrome. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract Plenary. https://www.shmabstracts.com/abstract/decreasing-admissions-readmissions-and-length-of-stay-while-improving-patient-safety-for-alcohol-withdrawal-syndrome/.

Hospitalists in the VA system see patients with symptoms of alcohol withdrawal frequently – there are about 33,000 hospital admissions each year for alcohol withdrawal syndrome (AWS), says Robert Patrick, MD, of the Louis Stokes Cleveland VA Medical Center.

“By contrast, the number of admissions for the largest ambulatory care sensitive condition (heart failure) is only about 28,000,” he said. “If alcohol detox were an ambulatory care sensitive condition, it would be the largest in the VA by a substantial margin.”The purpose of the project he and his co-author, Laura Brown, MD, created to address the problem was to increase the number of patients treated for AWS as outpatients and decrease hospital admissions – without increasing readmissions or clinical deterioration.

They introduced four core operational changes for their study:

1. Standardized risk stratification in the Emergency Department (ED) to identify low risk patients for outpatient treatment.

2. Benzodiazepine sparing symptom triggered medication regimen.

3. Daily clinical dashboard surveillance and risk stratification for continued hospital stay.

4. Telephone follow-up for patients discharged from the ED or hospital.

With these changes in place, eight months of data showed a 50% reduction in AWS admissions and a 40% reduction in length of stays.

Their conclusion? “A well designed and executed QI project can dramatically reduce hospitalist workload, while at the same time improving patient safety,” Dr. Patrick said. “Hospitalists just have to be willing to think outside the box, work with nursing and coordinate care outside of the hospital to make it happen.”

He added a caveat for hospital medicine groups still in a fee-for-service environment. “This saves money for the payer, not the hospital,” he said. “In our case they are one and the same, so the ROI is huge. If you are part of an ACO this is probably true for you, but I would check with your ACO first.”
 

Reference

1. Patrick RM, Brown LZ. Decreasing Admissions, Readmissions and Length of Stay While Improving Patent Safety for Alcohol Withdrawal Syndrome. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract Plenary. https://www.shmabstracts.com/abstract/decreasing-admissions-readmissions-and-length-of-stay-while-improving-patient-safety-for-alcohol-withdrawal-syndrome/.

Hospitalists in the VA system see patients with symptoms of alcohol withdrawal frequently – there are about 33,000 hospital admissions each year for alcohol withdrawal syndrome (AWS), says Robert Patrick, MD, of the Louis Stokes Cleveland VA Medical Center.

“By contrast, the number of admissions for the largest ambulatory care sensitive condition (heart failure) is only about 28,000,” he said. “If alcohol detox were an ambulatory care sensitive condition, it would be the largest in the VA by a substantial margin.”The purpose of the project he and his co-author, Laura Brown, MD, created to address the problem was to increase the number of patients treated for AWS as outpatients and decrease hospital admissions – without increasing readmissions or clinical deterioration.

They introduced four core operational changes for their study:

1. Standardized risk stratification in the Emergency Department (ED) to identify low risk patients for outpatient treatment.

2. Benzodiazepine sparing symptom triggered medication regimen.

3. Daily clinical dashboard surveillance and risk stratification for continued hospital stay.

4. Telephone follow-up for patients discharged from the ED or hospital.

With these changes in place, eight months of data showed a 50% reduction in AWS admissions and a 40% reduction in length of stays.

Their conclusion? “A well designed and executed QI project can dramatically reduce hospitalist workload, while at the same time improving patient safety,” Dr. Patrick said. “Hospitalists just have to be willing to think outside the box, work with nursing and coordinate care outside of the hospital to make it happen.”

He added a caveat for hospital medicine groups still in a fee-for-service environment. “This saves money for the payer, not the hospital,” he said. “In our case they are one and the same, so the ROI is huge. If you are part of an ACO this is probably true for you, but I would check with your ACO first.”
 

Reference

1. Patrick RM, Brown LZ. Decreasing Admissions, Readmissions and Length of Stay While Improving Patent Safety for Alcohol Withdrawal Syndrome. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract Plenary. https://www.shmabstracts.com/abstract/decreasing-admissions-readmissions-and-length-of-stay-while-improving-patient-safety-for-alcohol-withdrawal-syndrome/.

Background: Studies have suggested that adrenal incidentalomas may increase risk of cardiometabolic disease in patients. Guidelines for repeat imaging and hormonal assessment of adrenal incidentalomas are inconsistent because of inadequate studies.

Bottom line: Patients with adrenal adenomas should be counseled on modifying cardiovascular risk factors whereas tumor growth, change in hormone production, and malignant transformation are less concerning based on the studies included.

Citation: Elhassan YS et al. Natural history of adrenal incidentalomas with and without mild autonomous cortisol excess: A systematic review and meta-analysis. Ann Intern Med. 2019 Jun 25;121:107-16.

Dr. Thompson is a hospitalist and assistant professor of medicine in the division of general internal medicine at Saint Louis University School of Medicine.

Background: Studies have suggested that adrenal incidentalomas may increase risk of cardiometabolic disease in patients. Guidelines for repeat imaging and hormonal assessment of adrenal incidentalomas are inconsistent because of inadequate studies.

Bottom line: Patients with adrenal adenomas should be counseled on modifying cardiovascular risk factors whereas tumor growth, change in hormone production, and malignant transformation are less concerning based on the studies included.

Citation: Elhassan YS et al. Natural history of adrenal incidentalomas with and without mild autonomous cortisol excess: A systematic review and meta-analysis. Ann Intern Med. 2019 Jun 25;121:107-16.

Dr. Thompson is a hospitalist and assistant professor of medicine in the division of general internal medicine at Saint Louis University School of Medicine.

Background: Studies have suggested that adrenal incidentalomas may increase risk of cardiometabolic disease in patients. Guidelines for repeat imaging and hormonal assessment of adrenal incidentalomas are inconsistent because of inadequate studies.

Bottom line: Patients with adrenal adenomas should be counseled on modifying cardiovascular risk factors whereas tumor growth, change in hormone production, and malignant transformation are less concerning based on the studies included.

Citation: Elhassan YS et al. Natural history of adrenal incidentalomas with and without mild autonomous cortisol excess: A systematic review and meta-analysis. Ann Intern Med. 2019 Jun 25;121:107-16.

Dr. Thompson is a hospitalist and assistant professor of medicine in the division of general internal medicine at Saint Louis University School of Medicine.