Brian Kwan, MD

Posttraumatic stress disorder (PTSD) is a syndrome that occurs after exposure to a significant traumatic event and is characterized by persistent, debilitating symptoms that fall into four “diagnostic clusters” as outlined in the Diagnostic and Statistical Manual of Mental Disorders-Version V (DSM-V). Patients may experience intrusive thoughts, avoidance of distressing stimuli, persistent negative mood, and hypervigilance, all of which last longer than 1 month.¹

A national survey of United States households conducted during 2001-2003 estimated the 12-month prevalence of PTSD among adults to be 3.5%.² Lifetime prevalence has been found to be between 6.8%³ and 7.8%.⁴ PTSD is more common in veterans. The prevalence of PTSD in veterans differs depending on the conflict in which the veteran participated. Vietnam veterans have an estimated lifetime prevalence of approximately 30%,^5,6 Gulf War veterans approximately 15%,⁷ and veterans of more recent conflicts in Afghanistan and Iraq of approximately 21%.⁸ With the MISSION Act moving more veteran care into the private sector, non-VA inpatient providers will need to become better versed in PTSD.⁹

Patients with PTSD have more contact with the healthcare system, even for non–mental health problems,^8,10-13 and a significantly higher burden of medical comorbities,¹⁴ such as diabetes mellitus, liver disease, gastritis and gastric ulcers, HIV, arthritis,¹⁵ and coronary heart disease.¹⁶ Veterans with PTSD are hospitalized three times more often than are those with no mental health diagnoses,⁸ and patients with psychiatric comorbidities have higher lengths of stay.¹⁷ More than 1.4 million hospitalizations occurring during 2002-2011 had either a primary or secondary associated diagnosis of PTSD, with total inflation-­adjusted charges of 34.9 billion dollars.¹⁸ In the inpatient sample from this study, greater than half were admitted for a primary diagnosis of mental diseases and disorders (Major Diagnostic Category [MDC] 19). Following mental illness, the most common primary diagnoses for men were MDC 5 (Circulatory System, 12.1%), MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 9.2%), and MDC 4 (Respiratory System, 7.4%), while the most common categories for women were MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 5.8%), MDC 21 (Injuries, Poison, and Toxic Effect of Drugs, 4.9%), and MDC 6 (Digestive System, 4.5%).¹⁸

In both the inpatient and outpatient settings, a fundamental challenge to comprehensive PTSD management is correctly diagnosing this condition.¹⁹ Confounding the difficulties in diagnosis are numerous comorbidities. In addition to the physical comorbidities described above, more than 70% of patients with PTSD have another psychological comorbidity such as affective disorders, anxiety disorders, or substance use disorder/dependency.²⁰

Given that PTSD may be an underrecognized burden on the healthcare system, we sought to better understand how PTSD could affect hospitalized patients admitted for medical problems by conducting this narrative review. Additionally, three of the authors collaborated with the VA Employee Education Service to conduct a needs assessment of VA hospitalists in 2013. Respondents identified managing and educating patients and families about PTSD as a major educational need (unpublished data available upon request from the corresponding author). Therefore, our aims were to present a synthesis of existing literature, familiarize readers with the tenets of trauma-­informed care as a framework to guide care for these patients, and generate ideas for changes that inpatient providers could implement now. We began by consulting a research librarian at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, who searched the following databases: PsycInfo, CINAHL, MEDLINE, and PILOTS (a PTSD/trauma specific database). Search terms included hospital, hospitalized, and hospitalization, as well as traumatic stress, posttraumatic stress, and PTSD. Pertinent guidelines and the reference lists from included papers were examined. We focused on papers that described patients admitted for medical problems other than PTSD because those patients who are admitted for PTSD-­related problems should be primarily ma­naged by psychiatry (not hospitalists) with the primary focus of their hospitalization being their PTSD. We also excluded papers about patients developing PTSD secondary to hospitalization, which already has a well-developed literature.^21-23

The literature is sparse describing frequency or type of problems encountered by hospitalized medical patients with PTSD. A recent small survey study reported that 40% of patients anticipated triggers for their PTSD symptoms in the hospital; such triggers included loud noises and being shaken awake.²⁴ Two papers describe case vignettes of patients who had exacerbations of their PTSD while in the Intensive Care Unit (ICU), although neither contain frequency or severity data.^25,26 Approximately 8% of patients in VA ICUs have PTSD,²⁷ and a published abstract suggests that they appear to require more sedation than do patients without PTSD.²⁸ Another published case report describes a patient with recurrent PTSD symptoms (nightmares) after moving into a nursing home.²⁹ These papers suggest other providers have recognized and are concerned about hospitalized patients with PTSD. At present, there are no data to quantify how often hospitalized patients have PTSD exacerbations or how troublesome such exacerbations are to these patients.

Given that there is little empiric literature to guide inpatient management of PTSD as a comorbidity in hospitalized medical patients, we extrapolate some information from the outpatient setting. PTSD is often underdiagnosed and underreported by individual patients in the outpatient setting.³⁰ Failure to have an associated diagnosis of PTSD may lead to underrecognition and undertreatment of these patients by inpatient providers in the hospital setting. Additionally, the numerous psychological and physical comorbidities in PTSD can create unique challenges in properly managing any single problem in these patients.²⁰ Armed with this knowledge, providers should be vigilant in the recognition, assessment, and treatment of PTSD.

Trauma-Informed Care: A Conceptual Model

Trauma-informed care is a mindful and sensitive approach to caring for patients who have suffered trauma.³¹ It requires understanding that many people have suffered trauma in their lives and that the trauma continues to impact many aspects of their lives.³² Trauma-informed care has many advocates and has been implemented across myriad health and social services settings.³³ Its principles can be applied in both the inpatient and outpatient hospital settings. While it is an appropriate approach to patients with PTSD, it is not specific to PTSD. People who have suffered sexual trauma, intimate partner violence, child abuse, or other exposures would also be included in the group of people for whom trauma-informed care is a suitable approach. There are four key assumptions to a trauma-­informed approach to care (the 4 R’s): (1) realization that trauma affects an individual’s coping strategies, relationships, and health; (2) recognition of the signs of trauma; (3) having an appropriate, planned response to patients identified as having suffered a trauma; and (4) resisting retraumatization in the care setting.^31,32

General Approach to Treating Medical Patients With PTSD in the Inpatient Setting

Recognition

Consistent with a trauma-informed care approach, inpatient providers should be able to recognize patients who may have PTSD. First, careful review of the past medical history may show some patients already carry this diagnosis. Second, patients with PTSD often have other comorbidities that could offer a clue that PTSD could be present as well; for example, risk for PTSD is increased when mood, anxiety, or substance use disorders are present.²⁰ When PTSD is suspected, screening is a reasonable next step.

The Primary Care-PTSD-5 (PC-PTSD-5) is a validated screening tool used in the outpatient setting.³⁴ It is easily administered and has good predictive validity (positive likelihood ratio [LR+] of 6.33 and LR– of 0.06). It begins with a question of whether the patient has ever experienced a trauma. A positive initial response triggers a series of five yes/no questions. Answering “yes” to three or more questions is a positive screen. A positive screen should result in consultation to psychiatry to conduct more formal evaluation and guide longer-term management.

Collaboration

Individual trauma-focused psychotherapy is the primary treatment of choice for PTSD with strong evidence supporting its practice.³⁵ This treatment is administered by a psychiatrist or psychologist and will be limited in the inpatient medical setting. Current recommendations suggest pharmacotherapy only when individualized trauma-focused psychotherapy is not available, the patient declines it, or as an adjunct when psychotherapy alone is not effective.³⁶ Therefore, inpatient providers may see patients who are prescribed selective serotonin reuptake inhibitors (eg, paroxetine, fluoxetine) or serotonin and norepinephrine reuptake inhibitors (eg, venlafaxine).³⁶ In the past, PTSD-related nightmares were often treated with prazosin.³⁷ However, a recent randomized controlled trial of prazosin in veterans with PTSD failed to show significant improvement in nightmares.³⁸ Hence, current guidelines do not recommend prazosin as a first-line therapy.³⁹ For hospitalized patients with PTSD symptoms refractory to the interventions outlined herein, particularly those patients with possible borderline personality traits (as suggested by severe anger and impulsivity), we strongly recommend partnering with psychiatry. Finally, given the high prevalence of substance use disorders (SUDs) in PTSD patients, awareness and treatment of comorbidities such as opioid and alcohol dependence must be concurrently addressed.

Individualizing Care

It is essential for the healthcare team to identify ways to meet each patient’s immediate needs. Many of the ideas proposed below are not specific to PTSD; many require an interprofessional approach to care.⁴⁰ From a trauma-informed care standpoint, this is akin to having a planned response for patients who have suffered trauma. Assessing the individual’s needs and incorporating therapeutic modalities such as reflective listening, broadening safe opportunities for control, and providing complementary and integrative medicine (IM) therapies may help manage symptoms and establish rapport.⁴¹ Through reflective listening, a collaborative approach can be established to identify background, triggers, and a safe approach for managing PTSD and its comorbid conditions. Ensuring frequent communication and allowing the patient to be at the center of decision-making establishes a safe environment and promotes positive rapport between the patient and healthcare team.³⁶ Providing a sense of control by involving the patients in their healthcare decisions and in the structure of care delivery may benefit the patients’ well-being. Furthermore, incorporating IM encourages rest and relaxation in the chaotic hospital environment. Suggested IM interventions include deep breathing, aromatherapy, guided imagery, muscle relaxation, and music therapy.^42,43

Key Inpatient Issues Affecting PTSD

In the following sections, we outline common clinical situations that may exacerbate PTSD symptoms and propose some evidence-based responses (Table). In general, nonpharmacologic approaches are favored over pharmacologic approaches for patients with PTSD.

Sleep Hygiene

Sleep problems are very common in patients with PTSD, with nightmares occurring in more than 70% of patients and insomnia in 80%.⁴⁴ In PTSD, sleep problems are linked to poor physical health and other health outcomes^45,46 and may exacerbate other PTSD symptoms.⁴

Treating the sleep problems that occur with PTSD is an important aspect of PTSD care. Usually administered in the outpatient setting, the treatment of choice is cognitive-behavioral therapy (CBT).⁴⁸ Sleep-specific CBT focuses, among other things, on strategies that encourage good sleep hygiene,⁴⁹ which includes promoting regular sleep/wake-up times and specific bedtime routines, avoiding stimulation (eg, light, noise, TV) or excessive liquids before bed, refraining from daytime naps, and using relaxation techniques. Many of these recommendations seem at odds with hospital routines, which may contribute to decompensation of hospitalized patients with PTSD.

While starting sleep-specific CBT in the hospital may not be realistic, we suggest the following goals and strategies as a starting place for promoting healthy sleep for hospitalized patients with PTSD. To begin, factors affecting sleep hygiene should be addressed. Inpatient providers could pay more attention to intravenous (IV) fluid orders, perhaps adjusting them to run only during the daytime hours. Medications can be scheduled at times conducive to maintaining home routines. Avoiding the administration of diuretics close to bedtime may decrease the likelihood of frequent nighttime wakening. Grouping patient care activities, such as bathing or wound care, during daytime hours may allow more opportunities for rest at night. Incorporating uninterrupted sleep protocols, such as quiet hours between 10pm and 6am, may enhance sleep quality in the appropriately selected patient.⁵⁰ Although pharmacological interventions to improve sleep in the hospital may be initially beneficial, nonpharmacological interventions as described above should be incorporated for long-term maintenance of enhanced sleep quality.

Second, providers need to ask about established home bedtime routines and facilitate implementation in the hospital. Through collaboration with patients, providers can incorporate an individualized plan of care for sleep early in hospitalization.⁵⁰ Partnering with nurses is also essential to creating a sleep-friendly environment that can improve patient experiences.⁵¹ Breathing exercises, meditating, listening to music and praying are all examples of “bedtime wind down” strategies recommended in sleep-specific CBT.⁴⁹ Many of these could be successfully implemented in the hospital and may benefit other hospitalized patients too.⁵² In patients with PTSD and obstructive sleep apnea, continuous positive airway pressure (CPAP) reduces nightmares, and if inpatients are on CPAP at home, it should be continued in the hospital.⁵³

Pain

If sleep disturbance is the hallmark of PTSD,⁴⁷ chronic pain is its coconspirator.¹⁵ Uncontrolled pain can make it much more difficult to treat patients with PTSD, which in turn may lead to further decompensation from a mental health standpoint.⁵⁴ SUDs such as alcohol or opioid dependencies are highly comorbid with PTSD⁴⁵ and introduce a layer of complexity when managing painin these patients. Providers should be thoughtful when electing to treat acute or chronic pain with opioids and take particular care to establish realistic therapeutic goals if doing so. While patients with PTSD have a greater likelihood of having an SUD, undertreating pain risks exacerbating underlying PTSD symptoms.

Nonpharmacologic therapies, which include communicating, listening, and expressing compassion and understanding, should be utilized by inpatient providers as a first-line treatment in patients with PTSD who suffer from pain. Additionally, relaxation techniques, physical therapy, and physical activity⁵⁵ can be offered. Pharmacologically, nonopioid medications such as acetaminophen or NSAIDs should always be considered first. Should the use of opioids be deemed necessary, inpatient providers should preferentially use oral over intravenous medications and consider establishing a fixed timeframe for short-term opioids, which should be limited to a few days. Providers should communicate clear expectations with their patients to maximize the desired effect of any specific treatment while minimizing the risk of medication side effects with the goal of agreeing on a short yet effective treatment course.

Anxiety and Anger

One of the most challenging situations for the inpatient provider is encountering a patient who is anxious, angry, or hypervigilant. Mismatch between actual and expected communication between the provider and the patient can lead to frustration and anxiety. A trauma-informed care approach would suggest that frequent and thorough communication with patients may prevent or ameliorate the stresses and anxieties of hospitalization that may manifest as anger because of retraumatization. Hospitalizations usually lead to disruption of normal routine (eg, unpredictable meal times or medication administration), interrupted sleep (eg, woken up for blood draws or provider evaluation), and lack of control of schedule (eg, unsure of exact time when a procedure may be occurring), any of which may trigger symptoms of anxiety and anger in patients with PTSD and lead to hypervigilance.

If situations involving patient anxiety do arise, employ compassion and communication. Extra time spent with the patient, while challenging in the hectic hospital environment, is critical, and nonpharmacological treatments should be the priority. Engaging patients by asking about their PTSD triggers²⁴ may help prevent exacerbations. For example, some patients may specify how they prefer to be woken up to prevent startle reactions. PTSD triggers can be reduced via effective communication with the entire healthcare team. Some immediate yet effective strategies are listening, validation, and negotiation. Benzodiazepine or antipsychotic usage should be avoided.³⁶ Inpatient social work and comanagement with psychiatry involvement may be helpful in more severe exacerbations. A small observational study of patients hospitalized for severe PTSD found an association between walking more during hospitalization and fewer PTSD symptoms,⁵⁶ suggesting that staying active could be helpful for inpatients with PTSD who are able to safely ambulate.

PTSD is a common comorbidity among hospitalized patients in the United States. Typical hospital routines may exacerbate symptoms of PTSD such as anxiety and anger. Inpatient providers can play an important role in making hospitalizations go more smoothly for these patients by using principles consistent with trauma-informed care. Specifically, partnering with patients to construct a plan that preserves their sleep routines and accounts for potential triggers for decompensation can improve the hospital experience for patients with PTSD. Some PTSD interventions require additional investment from the healthcare system to deploy, such as staff training in trauma-­informed care and reflective listening techniques. Electronic health record–based protocols and order sets for patients with PTSD can leverage available resources. Further research should evaluate hospital outcomes that result from a more tailored approach to the care of patients with PTSD. More effective, patient-centered PTSD care could lower rates of leaving against medical advice and improve the inpatient experience for patients and providers alike.

Posttraumatic stress disorder (PTSD) is a syndrome that occurs after exposure to a significant traumatic event and is characterized by persistent, debilitating symptoms that fall into four “diagnostic clusters” as outlined in the Diagnostic and Statistical Manual of Mental Disorders-Version V (DSM-V). Patients may experience intrusive thoughts, avoidance of distressing stimuli, persistent negative mood, and hypervigilance, all of which last longer than 1 month.¹

A national survey of United States households conducted during 2001-2003 estimated the 12-month prevalence of PTSD among adults to be 3.5%.² Lifetime prevalence has been found to be between 6.8%³ and 7.8%.⁴ PTSD is more common in veterans. The prevalence of PTSD in veterans differs depending on the conflict in which the veteran participated. Vietnam veterans have an estimated lifetime prevalence of approximately 30%,^5,6 Gulf War veterans approximately 15%,⁷ and veterans of more recent conflicts in Afghanistan and Iraq of approximately 21%.⁸ With the MISSION Act moving more veteran care into the private sector, non-VA inpatient providers will need to become better versed in PTSD.⁹

Patients with PTSD have more contact with the healthcare system, even for non–mental health problems,^8,10-13 and a significantly higher burden of medical comorbities,¹⁴ such as diabetes mellitus, liver disease, gastritis and gastric ulcers, HIV, arthritis,¹⁵ and coronary heart disease.¹⁶ Veterans with PTSD are hospitalized three times more often than are those with no mental health diagnoses,⁸ and patients with psychiatric comorbidities have higher lengths of stay.¹⁷ More than 1.4 million hospitalizations occurring during 2002-2011 had either a primary or secondary associated diagnosis of PTSD, with total inflation-­adjusted charges of 34.9 billion dollars.¹⁸ In the inpatient sample from this study, greater than half were admitted for a primary diagnosis of mental diseases and disorders (Major Diagnostic Category [MDC] 19). Following mental illness, the most common primary diagnoses for men were MDC 5 (Circulatory System, 12.1%), MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 9.2%), and MDC 4 (Respiratory System, 7.4%), while the most common categories for women were MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 5.8%), MDC 21 (Injuries, Poison, and Toxic Effect of Drugs, 4.9%), and MDC 6 (Digestive System, 4.5%).¹⁸

In both the inpatient and outpatient settings, a fundamental challenge to comprehensive PTSD management is correctly diagnosing this condition.¹⁹ Confounding the difficulties in diagnosis are numerous comorbidities. In addition to the physical comorbidities described above, more than 70% of patients with PTSD have another psychological comorbidity such as affective disorders, anxiety disorders, or substance use disorder/dependency.²⁰

Given that PTSD may be an underrecognized burden on the healthcare system, we sought to better understand how PTSD could affect hospitalized patients admitted for medical problems by conducting this narrative review. Additionally, three of the authors collaborated with the VA Employee Education Service to conduct a needs assessment of VA hospitalists in 2013. Respondents identified managing and educating patients and families about PTSD as a major educational need (unpublished data available upon request from the corresponding author). Therefore, our aims were to present a synthesis of existing literature, familiarize readers with the tenets of trauma-­informed care as a framework to guide care for these patients, and generate ideas for changes that inpatient providers could implement now. We began by consulting a research librarian at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, who searched the following databases: PsycInfo, CINAHL, MEDLINE, and PILOTS (a PTSD/trauma specific database). Search terms included hospital, hospitalized, and hospitalization, as well as traumatic stress, posttraumatic stress, and PTSD. Pertinent guidelines and the reference lists from included papers were examined. We focused on papers that described patients admitted for medical problems other than PTSD because those patients who are admitted for PTSD-­related problems should be primarily ma­naged by psychiatry (not hospitalists) with the primary focus of their hospitalization being their PTSD. We also excluded papers about patients developing PTSD secondary to hospitalization, which already has a well-developed literature.^21-23

The literature is sparse describing frequency or type of problems encountered by hospitalized medical patients with PTSD. A recent small survey study reported that 40% of patients anticipated triggers for their PTSD symptoms in the hospital; such triggers included loud noises and being shaken awake.²⁴ Two papers describe case vignettes of patients who had exacerbations of their PTSD while in the Intensive Care Unit (ICU), although neither contain frequency or severity data.^25,26 Approximately 8% of patients in VA ICUs have PTSD,²⁷ and a published abstract suggests that they appear to require more sedation than do patients without PTSD.²⁸ Another published case report describes a patient with recurrent PTSD symptoms (nightmares) after moving into a nursing home.²⁹ These papers suggest other providers have recognized and are concerned about hospitalized patients with PTSD. At present, there are no data to quantify how often hospitalized patients have PTSD exacerbations or how troublesome such exacerbations are to these patients.

Given that there is little empiric literature to guide inpatient management of PTSD as a comorbidity in hospitalized medical patients, we extrapolate some information from the outpatient setting. PTSD is often underdiagnosed and underreported by individual patients in the outpatient setting.³⁰ Failure to have an associated diagnosis of PTSD may lead to underrecognition and undertreatment of these patients by inpatient providers in the hospital setting. Additionally, the numerous psychological and physical comorbidities in PTSD can create unique challenges in properly managing any single problem in these patients.²⁰ Armed with this knowledge, providers should be vigilant in the recognition, assessment, and treatment of PTSD.

Trauma-Informed Care: A Conceptual Model

Trauma-informed care is a mindful and sensitive approach to caring for patients who have suffered trauma.³¹ It requires understanding that many people have suffered trauma in their lives and that the trauma continues to impact many aspects of their lives.³² Trauma-informed care has many advocates and has been implemented across myriad health and social services settings.³³ Its principles can be applied in both the inpatient and outpatient hospital settings. While it is an appropriate approach to patients with PTSD, it is not specific to PTSD. People who have suffered sexual trauma, intimate partner violence, child abuse, or other exposures would also be included in the group of people for whom trauma-informed care is a suitable approach. There are four key assumptions to a trauma-­informed approach to care (the 4 R’s): (1) realization that trauma affects an individual’s coping strategies, relationships, and health; (2) recognition of the signs of trauma; (3) having an appropriate, planned response to patients identified as having suffered a trauma; and (4) resisting retraumatization in the care setting.^31,32

General Approach to Treating Medical Patients With PTSD in the Inpatient Setting

Recognition

Consistent with a trauma-informed care approach, inpatient providers should be able to recognize patients who may have PTSD. First, careful review of the past medical history may show some patients already carry this diagnosis. Second, patients with PTSD often have other comorbidities that could offer a clue that PTSD could be present as well; for example, risk for PTSD is increased when mood, anxiety, or substance use disorders are present.²⁰ When PTSD is suspected, screening is a reasonable next step.

The Primary Care-PTSD-5 (PC-PTSD-5) is a validated screening tool used in the outpatient setting.³⁴ It is easily administered and has good predictive validity (positive likelihood ratio [LR+] of 6.33 and LR– of 0.06). It begins with a question of whether the patient has ever experienced a trauma. A positive initial response triggers a series of five yes/no questions. Answering “yes” to three or more questions is a positive screen. A positive screen should result in consultation to psychiatry to conduct more formal evaluation and guide longer-term management.

Collaboration

Individual trauma-focused psychotherapy is the primary treatment of choice for PTSD with strong evidence supporting its practice.³⁵ This treatment is administered by a psychiatrist or psychologist and will be limited in the inpatient medical setting. Current recommendations suggest pharmacotherapy only when individualized trauma-focused psychotherapy is not available, the patient declines it, or as an adjunct when psychotherapy alone is not effective.³⁶ Therefore, inpatient providers may see patients who are prescribed selective serotonin reuptake inhibitors (eg, paroxetine, fluoxetine) or serotonin and norepinephrine reuptake inhibitors (eg, venlafaxine).³⁶ In the past, PTSD-related nightmares were often treated with prazosin.³⁷ However, a recent randomized controlled trial of prazosin in veterans with PTSD failed to show significant improvement in nightmares.³⁸ Hence, current guidelines do not recommend prazosin as a first-line therapy.³⁹ For hospitalized patients with PTSD symptoms refractory to the interventions outlined herein, particularly those patients with possible borderline personality traits (as suggested by severe anger and impulsivity), we strongly recommend partnering with psychiatry. Finally, given the high prevalence of substance use disorders (SUDs) in PTSD patients, awareness and treatment of comorbidities such as opioid and alcohol dependence must be concurrently addressed.

Individualizing Care

It is essential for the healthcare team to identify ways to meet each patient’s immediate needs. Many of the ideas proposed below are not specific to PTSD; many require an interprofessional approach to care.⁴⁰ From a trauma-informed care standpoint, this is akin to having a planned response for patients who have suffered trauma. Assessing the individual’s needs and incorporating therapeutic modalities such as reflective listening, broadening safe opportunities for control, and providing complementary and integrative medicine (IM) therapies may help manage symptoms and establish rapport.⁴¹ Through reflective listening, a collaborative approach can be established to identify background, triggers, and a safe approach for managing PTSD and its comorbid conditions. Ensuring frequent communication and allowing the patient to be at the center of decision-making establishes a safe environment and promotes positive rapport between the patient and healthcare team.³⁶ Providing a sense of control by involving the patients in their healthcare decisions and in the structure of care delivery may benefit the patients’ well-being. Furthermore, incorporating IM encourages rest and relaxation in the chaotic hospital environment. Suggested IM interventions include deep breathing, aromatherapy, guided imagery, muscle relaxation, and music therapy.^42,43

Key Inpatient Issues Affecting PTSD

In the following sections, we outline common clinical situations that may exacerbate PTSD symptoms and propose some evidence-based responses (Table). In general, nonpharmacologic approaches are favored over pharmacologic approaches for patients with PTSD.

Sleep Hygiene

Sleep problems are very common in patients with PTSD, with nightmares occurring in more than 70% of patients and insomnia in 80%.⁴⁴ In PTSD, sleep problems are linked to poor physical health and other health outcomes^45,46 and may exacerbate other PTSD symptoms.⁴

Treating the sleep problems that occur with PTSD is an important aspect of PTSD care. Usually administered in the outpatient setting, the treatment of choice is cognitive-behavioral therapy (CBT).⁴⁸ Sleep-specific CBT focuses, among other things, on strategies that encourage good sleep hygiene,⁴⁹ which includes promoting regular sleep/wake-up times and specific bedtime routines, avoiding stimulation (eg, light, noise, TV) or excessive liquids before bed, refraining from daytime naps, and using relaxation techniques. Many of these recommendations seem at odds with hospital routines, which may contribute to decompensation of hospitalized patients with PTSD.

While starting sleep-specific CBT in the hospital may not be realistic, we suggest the following goals and strategies as a starting place for promoting healthy sleep for hospitalized patients with PTSD. To begin, factors affecting sleep hygiene should be addressed. Inpatient providers could pay more attention to intravenous (IV) fluid orders, perhaps adjusting them to run only during the daytime hours. Medications can be scheduled at times conducive to maintaining home routines. Avoiding the administration of diuretics close to bedtime may decrease the likelihood of frequent nighttime wakening. Grouping patient care activities, such as bathing or wound care, during daytime hours may allow more opportunities for rest at night. Incorporating uninterrupted sleep protocols, such as quiet hours between 10pm and 6am, may enhance sleep quality in the appropriately selected patient.⁵⁰ Although pharmacological interventions to improve sleep in the hospital may be initially beneficial, nonpharmacological interventions as described above should be incorporated for long-term maintenance of enhanced sleep quality.

Second, providers need to ask about established home bedtime routines and facilitate implementation in the hospital. Through collaboration with patients, providers can incorporate an individualized plan of care for sleep early in hospitalization.⁵⁰ Partnering with nurses is also essential to creating a sleep-friendly environment that can improve patient experiences.⁵¹ Breathing exercises, meditating, listening to music and praying are all examples of “bedtime wind down” strategies recommended in sleep-specific CBT.⁴⁹ Many of these could be successfully implemented in the hospital and may benefit other hospitalized patients too.⁵² In patients with PTSD and obstructive sleep apnea, continuous positive airway pressure (CPAP) reduces nightmares, and if inpatients are on CPAP at home, it should be continued in the hospital.⁵³

Pain

If sleep disturbance is the hallmark of PTSD,⁴⁷ chronic pain is its coconspirator.¹⁵ Uncontrolled pain can make it much more difficult to treat patients with PTSD, which in turn may lead to further decompensation from a mental health standpoint.⁵⁴ SUDs such as alcohol or opioid dependencies are highly comorbid with PTSD⁴⁵ and introduce a layer of complexity when managing painin these patients. Providers should be thoughtful when electing to treat acute or chronic pain with opioids and take particular care to establish realistic therapeutic goals if doing so. While patients with PTSD have a greater likelihood of having an SUD, undertreating pain risks exacerbating underlying PTSD symptoms.

Nonpharmacologic therapies, which include communicating, listening, and expressing compassion and understanding, should be utilized by inpatient providers as a first-line treatment in patients with PTSD who suffer from pain. Additionally, relaxation techniques, physical therapy, and physical activity⁵⁵ can be offered. Pharmacologically, nonopioid medications such as acetaminophen or NSAIDs should always be considered first. Should the use of opioids be deemed necessary, inpatient providers should preferentially use oral over intravenous medications and consider establishing a fixed timeframe for short-term opioids, which should be limited to a few days. Providers should communicate clear expectations with their patients to maximize the desired effect of any specific treatment while minimizing the risk of medication side effects with the goal of agreeing on a short yet effective treatment course.

Anxiety and Anger

One of the most challenging situations for the inpatient provider is encountering a patient who is anxious, angry, or hypervigilant. Mismatch between actual and expected communication between the provider and the patient can lead to frustration and anxiety. A trauma-informed care approach would suggest that frequent and thorough communication with patients may prevent or ameliorate the stresses and anxieties of hospitalization that may manifest as anger because of retraumatization. Hospitalizations usually lead to disruption of normal routine (eg, unpredictable meal times or medication administration), interrupted sleep (eg, woken up for blood draws or provider evaluation), and lack of control of schedule (eg, unsure of exact time when a procedure may be occurring), any of which may trigger symptoms of anxiety and anger in patients with PTSD and lead to hypervigilance.

If situations involving patient anxiety do arise, employ compassion and communication. Extra time spent with the patient, while challenging in the hectic hospital environment, is critical, and nonpharmacological treatments should be the priority. Engaging patients by asking about their PTSD triggers²⁴ may help prevent exacerbations. For example, some patients may specify how they prefer to be woken up to prevent startle reactions. PTSD triggers can be reduced via effective communication with the entire healthcare team. Some immediate yet effective strategies are listening, validation, and negotiation. Benzodiazepine or antipsychotic usage should be avoided.³⁶ Inpatient social work and comanagement with psychiatry involvement may be helpful in more severe exacerbations. A small observational study of patients hospitalized for severe PTSD found an association between walking more during hospitalization and fewer PTSD symptoms,⁵⁶ suggesting that staying active could be helpful for inpatients with PTSD who are able to safely ambulate.

PTSD is a common comorbidity among hospitalized patients in the United States. Typical hospital routines may exacerbate symptoms of PTSD such as anxiety and anger. Inpatient providers can play an important role in making hospitalizations go more smoothly for these patients by using principles consistent with trauma-informed care. Specifically, partnering with patients to construct a plan that preserves their sleep routines and accounts for potential triggers for decompensation can improve the hospital experience for patients with PTSD. Some PTSD interventions require additional investment from the healthcare system to deploy, such as staff training in trauma-­informed care and reflective listening techniques. Electronic health record–based protocols and order sets for patients with PTSD can leverage available resources. Further research should evaluate hospital outcomes that result from a more tailored approach to the care of patients with PTSD. More effective, patient-centered PTSD care could lower rates of leaving against medical advice and improve the inpatient experience for patients and providers alike.

Posttraumatic stress disorder (PTSD) is a syndrome that occurs after exposure to a significant traumatic event and is characterized by persistent, debilitating symptoms that fall into four “diagnostic clusters” as outlined in the Diagnostic and Statistical Manual of Mental Disorders-Version V (DSM-V). Patients may experience intrusive thoughts, avoidance of distressing stimuli, persistent negative mood, and hypervigilance, all of which last longer than 1 month.¹

A national survey of United States households conducted during 2001-2003 estimated the 12-month prevalence of PTSD among adults to be 3.5%.² Lifetime prevalence has been found to be between 6.8%³ and 7.8%.⁴ PTSD is more common in veterans. The prevalence of PTSD in veterans differs depending on the conflict in which the veteran participated. Vietnam veterans have an estimated lifetime prevalence of approximately 30%,^5,6 Gulf War veterans approximately 15%,⁷ and veterans of more recent conflicts in Afghanistan and Iraq of approximately 21%.⁸ With the MISSION Act moving more veteran care into the private sector, non-VA inpatient providers will need to become better versed in PTSD.⁹

Patients with PTSD have more contact with the healthcare system, even for non–mental health problems,^8,10-13 and a significantly higher burden of medical comorbities,¹⁴ such as diabetes mellitus, liver disease, gastritis and gastric ulcers, HIV, arthritis,¹⁵ and coronary heart disease.¹⁶ Veterans with PTSD are hospitalized three times more often than are those with no mental health diagnoses,⁸ and patients with psychiatric comorbidities have higher lengths of stay.¹⁷ More than 1.4 million hospitalizations occurring during 2002-2011 had either a primary or secondary associated diagnosis of PTSD, with total inflation-­adjusted charges of 34.9 billion dollars.¹⁸ In the inpatient sample from this study, greater than half were admitted for a primary diagnosis of mental diseases and disorders (Major Diagnostic Category [MDC] 19). Following mental illness, the most common primary diagnoses for men were MDC 5 (Circulatory System, 12.1%), MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 9.2%), and MDC 4 (Respiratory System, 7.4%), while the most common categories for women were MDC 20 (Alcohol/Drug Use or Induced Mental Disorder, 5.8%), MDC 21 (Injuries, Poison, and Toxic Effect of Drugs, 4.9%), and MDC 6 (Digestive System, 4.5%).¹⁸

In both the inpatient and outpatient settings, a fundamental challenge to comprehensive PTSD management is correctly diagnosing this condition.¹⁹ Confounding the difficulties in diagnosis are numerous comorbidities. In addition to the physical comorbidities described above, more than 70% of patients with PTSD have another psychological comorbidity such as affective disorders, anxiety disorders, or substance use disorder/dependency.²⁰

Given that PTSD may be an underrecognized burden on the healthcare system, we sought to better understand how PTSD could affect hospitalized patients admitted for medical problems by conducting this narrative review. Additionally, three of the authors collaborated with the VA Employee Education Service to conduct a needs assessment of VA hospitalists in 2013. Respondents identified managing and educating patients and families about PTSD as a major educational need (unpublished data available upon request from the corresponding author). Therefore, our aims were to present a synthesis of existing literature, familiarize readers with the tenets of trauma-­informed care as a framework to guide care for these patients, and generate ideas for changes that inpatient providers could implement now. We began by consulting a research librarian at the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin, who searched the following databases: PsycInfo, CINAHL, MEDLINE, and PILOTS (a PTSD/trauma specific database). Search terms included hospital, hospitalized, and hospitalization, as well as traumatic stress, posttraumatic stress, and PTSD. Pertinent guidelines and the reference lists from included papers were examined. We focused on papers that described patients admitted for medical problems other than PTSD because those patients who are admitted for PTSD-­related problems should be primarily ma­naged by psychiatry (not hospitalists) with the primary focus of their hospitalization being their PTSD. We also excluded papers about patients developing PTSD secondary to hospitalization, which already has a well-developed literature.^21-23

The literature is sparse describing frequency or type of problems encountered by hospitalized medical patients with PTSD. A recent small survey study reported that 40% of patients anticipated triggers for their PTSD symptoms in the hospital; such triggers included loud noises and being shaken awake.²⁴ Two papers describe case vignettes of patients who had exacerbations of their PTSD while in the Intensive Care Unit (ICU), although neither contain frequency or severity data.^25,26 Approximately 8% of patients in VA ICUs have PTSD,²⁷ and a published abstract suggests that they appear to require more sedation than do patients without PTSD.²⁸ Another published case report describes a patient with recurrent PTSD symptoms (nightmares) after moving into a nursing home.²⁹ These papers suggest other providers have recognized and are concerned about hospitalized patients with PTSD. At present, there are no data to quantify how often hospitalized patients have PTSD exacerbations or how troublesome such exacerbations are to these patients.

Given that there is little empiric literature to guide inpatient management of PTSD as a comorbidity in hospitalized medical patients, we extrapolate some information from the outpatient setting. PTSD is often underdiagnosed and underreported by individual patients in the outpatient setting.³⁰ Failure to have an associated diagnosis of PTSD may lead to underrecognition and undertreatment of these patients by inpatient providers in the hospital setting. Additionally, the numerous psychological and physical comorbidities in PTSD can create unique challenges in properly managing any single problem in these patients.²⁰ Armed with this knowledge, providers should be vigilant in the recognition, assessment, and treatment of PTSD.

Trauma-Informed Care: A Conceptual Model

Trauma-informed care is a mindful and sensitive approach to caring for patients who have suffered trauma.³¹ It requires understanding that many people have suffered trauma in their lives and that the trauma continues to impact many aspects of their lives.³² Trauma-informed care has many advocates and has been implemented across myriad health and social services settings.³³ Its principles can be applied in both the inpatient and outpatient hospital settings. While it is an appropriate approach to patients with PTSD, it is not specific to PTSD. People who have suffered sexual trauma, intimate partner violence, child abuse, or other exposures would also be included in the group of people for whom trauma-informed care is a suitable approach. There are four key assumptions to a trauma-­informed approach to care (the 4 R’s): (1) realization that trauma affects an individual’s coping strategies, relationships, and health; (2) recognition of the signs of trauma; (3) having an appropriate, planned response to patients identified as having suffered a trauma; and (4) resisting retraumatization in the care setting.^31,32

General Approach to Treating Medical Patients With PTSD in the Inpatient Setting

Recognition

Consistent with a trauma-informed care approach, inpatient providers should be able to recognize patients who may have PTSD. First, careful review of the past medical history may show some patients already carry this diagnosis. Second, patients with PTSD often have other comorbidities that could offer a clue that PTSD could be present as well; for example, risk for PTSD is increased when mood, anxiety, or substance use disorders are present.²⁰ When PTSD is suspected, screening is a reasonable next step.

The Primary Care-PTSD-5 (PC-PTSD-5) is a validated screening tool used in the outpatient setting.³⁴ It is easily administered and has good predictive validity (positive likelihood ratio [LR+] of 6.33 and LR– of 0.06). It begins with a question of whether the patient has ever experienced a trauma. A positive initial response triggers a series of five yes/no questions. Answering “yes” to three or more questions is a positive screen. A positive screen should result in consultation to psychiatry to conduct more formal evaluation and guide longer-term management.

Collaboration

Individual trauma-focused psychotherapy is the primary treatment of choice for PTSD with strong evidence supporting its practice.³⁵ This treatment is administered by a psychiatrist or psychologist and will be limited in the inpatient medical setting. Current recommendations suggest pharmacotherapy only when individualized trauma-focused psychotherapy is not available, the patient declines it, or as an adjunct when psychotherapy alone is not effective.³⁶ Therefore, inpatient providers may see patients who are prescribed selective serotonin reuptake inhibitors (eg, paroxetine, fluoxetine) or serotonin and norepinephrine reuptake inhibitors (eg, venlafaxine).³⁶ In the past, PTSD-related nightmares were often treated with prazosin.³⁷ However, a recent randomized controlled trial of prazosin in veterans with PTSD failed to show significant improvement in nightmares.³⁸ Hence, current guidelines do not recommend prazosin as a first-line therapy.³⁹ For hospitalized patients with PTSD symptoms refractory to the interventions outlined herein, particularly those patients with possible borderline personality traits (as suggested by severe anger and impulsivity), we strongly recommend partnering with psychiatry. Finally, given the high prevalence of substance use disorders (SUDs) in PTSD patients, awareness and treatment of comorbidities such as opioid and alcohol dependence must be concurrently addressed.

Individualizing Care

It is essential for the healthcare team to identify ways to meet each patient’s immediate needs. Many of the ideas proposed below are not specific to PTSD; many require an interprofessional approach to care.⁴⁰ From a trauma-informed care standpoint, this is akin to having a planned response for patients who have suffered trauma. Assessing the individual’s needs and incorporating therapeutic modalities such as reflective listening, broadening safe opportunities for control, and providing complementary and integrative medicine (IM) therapies may help manage symptoms and establish rapport.⁴¹ Through reflective listening, a collaborative approach can be established to identify background, triggers, and a safe approach for managing PTSD and its comorbid conditions. Ensuring frequent communication and allowing the patient to be at the center of decision-making establishes a safe environment and promotes positive rapport between the patient and healthcare team.³⁶ Providing a sense of control by involving the patients in their healthcare decisions and in the structure of care delivery may benefit the patients’ well-being. Furthermore, incorporating IM encourages rest and relaxation in the chaotic hospital environment. Suggested IM interventions include deep breathing, aromatherapy, guided imagery, muscle relaxation, and music therapy.^42,43

Key Inpatient Issues Affecting PTSD

In the following sections, we outline common clinical situations that may exacerbate PTSD symptoms and propose some evidence-based responses (Table). In general, nonpharmacologic approaches are favored over pharmacologic approaches for patients with PTSD.

Sleep Hygiene

Sleep problems are very common in patients with PTSD, with nightmares occurring in more than 70% of patients and insomnia in 80%.⁴⁴ In PTSD, sleep problems are linked to poor physical health and other health outcomes^45,46 and may exacerbate other PTSD symptoms.⁴

Treating the sleep problems that occur with PTSD is an important aspect of PTSD care. Usually administered in the outpatient setting, the treatment of choice is cognitive-behavioral therapy (CBT).⁴⁸ Sleep-specific CBT focuses, among other things, on strategies that encourage good sleep hygiene,⁴⁹ which includes promoting regular sleep/wake-up times and specific bedtime routines, avoiding stimulation (eg, light, noise, TV) or excessive liquids before bed, refraining from daytime naps, and using relaxation techniques. Many of these recommendations seem at odds with hospital routines, which may contribute to decompensation of hospitalized patients with PTSD.

While starting sleep-specific CBT in the hospital may not be realistic, we suggest the following goals and strategies as a starting place for promoting healthy sleep for hospitalized patients with PTSD. To begin, factors affecting sleep hygiene should be addressed. Inpatient providers could pay more attention to intravenous (IV) fluid orders, perhaps adjusting them to run only during the daytime hours. Medications can be scheduled at times conducive to maintaining home routines. Avoiding the administration of diuretics close to bedtime may decrease the likelihood of frequent nighttime wakening. Grouping patient care activities, such as bathing or wound care, during daytime hours may allow more opportunities for rest at night. Incorporating uninterrupted sleep protocols, such as quiet hours between 10pm and 6am, may enhance sleep quality in the appropriately selected patient.⁵⁰ Although pharmacological interventions to improve sleep in the hospital may be initially beneficial, nonpharmacological interventions as described above should be incorporated for long-term maintenance of enhanced sleep quality.

Second, providers need to ask about established home bedtime routines and facilitate implementation in the hospital. Through collaboration with patients, providers can incorporate an individualized plan of care for sleep early in hospitalization.⁵⁰ Partnering with nurses is also essential to creating a sleep-friendly environment that can improve patient experiences.⁵¹ Breathing exercises, meditating, listening to music and praying are all examples of “bedtime wind down” strategies recommended in sleep-specific CBT.⁴⁹ Many of these could be successfully implemented in the hospital and may benefit other hospitalized patients too.⁵² In patients with PTSD and obstructive sleep apnea, continuous positive airway pressure (CPAP) reduces nightmares, and if inpatients are on CPAP at home, it should be continued in the hospital.⁵³

Pain

If sleep disturbance is the hallmark of PTSD,⁴⁷ chronic pain is its coconspirator.¹⁵ Uncontrolled pain can make it much more difficult to treat patients with PTSD, which in turn may lead to further decompensation from a mental health standpoint.⁵⁴ SUDs such as alcohol or opioid dependencies are highly comorbid with PTSD⁴⁵ and introduce a layer of complexity when managing painin these patients. Providers should be thoughtful when electing to treat acute or chronic pain with opioids and take particular care to establish realistic therapeutic goals if doing so. While patients with PTSD have a greater likelihood of having an SUD, undertreating pain risks exacerbating underlying PTSD symptoms.

Nonpharmacologic therapies, which include communicating, listening, and expressing compassion and understanding, should be utilized by inpatient providers as a first-line treatment in patients with PTSD who suffer from pain. Additionally, relaxation techniques, physical therapy, and physical activity⁵⁵ can be offered. Pharmacologically, nonopioid medications such as acetaminophen or NSAIDs should always be considered first. Should the use of opioids be deemed necessary, inpatient providers should preferentially use oral over intravenous medications and consider establishing a fixed timeframe for short-term opioids, which should be limited to a few days. Providers should communicate clear expectations with their patients to maximize the desired effect of any specific treatment while minimizing the risk of medication side effects with the goal of agreeing on a short yet effective treatment course.

Anxiety and Anger

One of the most challenging situations for the inpatient provider is encountering a patient who is anxious, angry, or hypervigilant. Mismatch between actual and expected communication between the provider and the patient can lead to frustration and anxiety. A trauma-informed care approach would suggest that frequent and thorough communication with patients may prevent or ameliorate the stresses and anxieties of hospitalization that may manifest as anger because of retraumatization. Hospitalizations usually lead to disruption of normal routine (eg, unpredictable meal times or medication administration), interrupted sleep (eg, woken up for blood draws or provider evaluation), and lack of control of schedule (eg, unsure of exact time when a procedure may be occurring), any of which may trigger symptoms of anxiety and anger in patients with PTSD and lead to hypervigilance.

If situations involving patient anxiety do arise, employ compassion and communication. Extra time spent with the patient, while challenging in the hectic hospital environment, is critical, and nonpharmacological treatments should be the priority. Engaging patients by asking about their PTSD triggers²⁴ may help prevent exacerbations. For example, some patients may specify how they prefer to be woken up to prevent startle reactions. PTSD triggers can be reduced via effective communication with the entire healthcare team. Some immediate yet effective strategies are listening, validation, and negotiation. Benzodiazepine or antipsychotic usage should be avoided.³⁶ Inpatient social work and comanagement with psychiatry involvement may be helpful in more severe exacerbations. A small observational study of patients hospitalized for severe PTSD found an association between walking more during hospitalization and fewer PTSD symptoms,⁵⁶ suggesting that staying active could be helpful for inpatients with PTSD who are able to safely ambulate.

PTSD is a common comorbidity among hospitalized patients in the United States. Typical hospital routines may exacerbate symptoms of PTSD such as anxiety and anger. Inpatient providers can play an important role in making hospitalizations go more smoothly for these patients by using principles consistent with trauma-informed care. Specifically, partnering with patients to construct a plan that preserves their sleep routines and accounts for potential triggers for decompensation can improve the hospital experience for patients with PTSD. Some PTSD interventions require additional investment from the healthcare system to deploy, such as staff training in trauma-­informed care and reflective listening techniques. Electronic health record–based protocols and order sets for patients with PTSD can leverage available resources. Further research should evaluate hospital outcomes that result from a more tailored approach to the care of patients with PTSD. More effective, patient-centered PTSD care could lower rates of leaving against medical advice and improve the inpatient experience for patients and providers alike.

Hospital Medicine (HM) is medicine’s fastest growing specialty.¹ Rapid expansion of the field has been met with rising interest by young physicians, many of whom are first-time job seekers and may desire information on best practices for applying and interviewing in HM.^2-4 However, no prior work has examined HM-specific candidate qualifications and qualities that may be most valued in the hiring process.

As members of the Society of Hospital Medicine (SHM) Physicians in Training Committee, a group charged with “prepar[ing] trainees and early career hospitalists in their transition into hospital medicine,” we aimed to fill this knowledge gap around the HM-specific hiring process.

Survey Instrument

The authors developed the survey based on expertise as HM interviewers (JAD, AH, CD, EE, BK, DS, and SM) and local and national interview workshop leaders (JAD, CD, BK, SM). The questionnaire focused on objective applicant qualifications, qualities and attributes displayed during interviews (Appendix 1). Content, length, and reliability of physician understanding were assessed via feedback from local HM group leaders.

Respondents were asked to provide nonidentifying demographics and their role in their HM group’s hiring process. If they reported no role, the survey was terminated. Subsequent standardized HM group demographic questions were adapted from the Society of Hospital Medicine (SHM) State of Hospital Medicine Report.⁵

Survey questions were multiple choice, ranking and free-response aimed at understanding how respondents assess HM candidate attributes, skills, and behavior. For ranking questions, answer choice order was randomized to reduce answer order-based bias. One free-response question asked the respondent to provide a unique interview question they use that “reveals the most about a hospitalist candidate.” Responses were then individually inserted into the list of choices for a subsequent ranking question regarding the most important qualities a candidate must demonstrate.

Respondents were asked four open-ended questions designed to understand the approach to candidate assessment: (1) use of unique interview questions (as above); (2) identification of “red flags” during interviews; (3) distinctions between assessment of long-term (LT) career hospitalist candidates versus short-term (ST) candidates (eg, those seeking positions prior to fellowship); and (4) key qualifications of ST candidates.

Survey Administration

Survey recipients were identified via SHM administrative rosters. Surveys were distributed electronically via SHM to all current nontrainee physician members who reported a United States mailing address. The survey was determined to not constitute human subjects research by the Beth Israel Deaconess Medical Center Committee on Clinical Investigations.

Data Analysis

Multiple-choice responses were analyzed descriptively. For ranking-type questions, answers were weighted based on ranking order.

Responses to all open-ended survey questions were analyzed using thematic analysis. We used an iterative process to develop and refine codes identifying key concepts that emerged from the data. Three authors independently coded survey responses. As a group, research team members established the coding framework and resolved discrepancies via discussion to achieve consensus.

Survey links were sent to 8,398 e-mail addresses, of which 7,306 were undeliverable or unopened, leaving 1,092 total eligible respondents. Of these, 347 (31.8%) responded.

A total of 236 respondents reported having a formal role in HM hiring. Of these roles, 79.0% were one-on-one interviewers, 49.6% group interviewers, 45.5% telephone/videoconference interviewers, 41.5% participated on a selection committee, and 32.1% identified as the ultimate decision-maker. Regarding graduate medical education teaching status, 42.0% of respondents identified their primary workplace as a community/affiliated teaching hospital, 33.05% as a university-based teaching hospital, and 23.0% as a nonteaching hospital. Additional characteristics are reported in Appendix 2.

Quantitative Analysis

Respondents ranked the top five qualifications of HM candidates and the top five qualities a candidate should demonstrate on the interview day to be considered for hiring (Table 1).

When asked to rate agreement with the statement “I evaluate and consider all hospital medicine candidates similarly, regardless of whether they articulate an interest in hospital medicine as a long-term career or as a short-term position before fellowship,” 99 (57.23%) respondents disagreed.

Qualitative Analysis

Thematic analysis of responses to open-ended survey questions identified several “red flag” themes (Table 2). Negative interactions with current providers or staff were commonly noted. Additional red flags were a lack of knowledge or interest in the specific HM group, an inability to articulate career goals, or abnormalities in employment history or application materials. Respondents identified an overly strong focus on lifestyle or salary as factors that might limit a candidate’s chance of advancing in the hiring process.

Responses to free-text questions additionally highlighted preferred questioning techniques and approaches to HM candidate assessment (Appendix 3). Many interview questions addressed candidate interest in a particular HM program and candidate responses to challenging scenarios they had encountered. Other questions explored career development. Respondents wanted LT candidates to have specific HM career goals, while they expected ST candidates to demonstrate commitment to and appreciation of HM as a discipline.

Some respondents described their approach to candidate assessment in terms of investment and risk. LT candidates were often viewed as investments in stability and performance; they were evaluated on current abilities and future potential as related to group-specific goals. Some respondents viewed hiring ST candidates as more risky given concerns that they might be less engaged or integrated with the group. Others viewed the hiring of LT candidates as comparably more risky, relating the longer time commitment to the potential for higher impact on the group and patient care. Accordingly, these respondents viewed ST candidate hiring as less risky, estimating their shorter time commitment as having less of a positive or negative impact, with the benefit of addressing urgent staffing issues or unfilled less desirable positions. One respondent summarized: “If they plan to be a career candidate, I care more about them as people and future coworkers. Short term folks are great if we are in a pinch and can deal with personality issues for a short period of time.”

Respondents also described how valued candidate qualities could help mitigate the risk inherent in hiring, especially for ST hires. Strong interpersonal and teamwork skills were highlighted, as well as a demonstrated record of clinical excellence, evidenced by strong training backgrounds and superlative references. A key factor aiding in ST hiring decisions was prior knowledge of the candidate, such as residents or moonlighters previously working in the respondent’s institution. This allowed for familiarity with the candidate’s clinical acumen as well as perceived ease of onboarding and knowledge of the system.

We present the results of a national survey of hospitalists identifying candidate attributes, skills, and behaviors viewed most favorably by those involved in the HM hiring process. To our knowledge, this is the first research to be published on the topic of evaluating HM candidates.

Survey respondents identified demonstrable HM candidate clinical skills and experience as highly important, consistent with prior research identifying clinical skills as being among those that hospitalists most value.⁶ Based on these responses, job seekers should be prepared to discuss objective measures of clinical experience when appropriate, such as number of cases seen or procedures performed. HM groups may accordingly consider the use of hiring rubrics or scoring systems to standardize these measures and reduce bias.

Respondents also highly valued more subjective assessments of HM applicants’ candidacy. The most highly ranked action item was a candidate’s ability to meaningfully respond to a respondent’s customized interview question. There was also a preference for candidates who were knowledgeable about and interested in the specifics of a particular HM group. The high value placed on these elements may suggest the need for formalized coaching or interview preparation for HM candidates. Similarly, interviewer emphasis on customized questions may also highlight an opportunity for HM groups to internally standardize how to best approach subjective components of the interview.

Our heterogeneous findings on the distinctions between ST and LT candidate hiring practices support the need for additional research on the ST HM job market. Until then, our findings reinforce the importance of applicant transparency about ST versus LT career goals. Although many programs may prefer LT candidates over ST candidates, our results suggest ST candidates may benefit from targeting groups with ST needs and using the application process as an opportunity to highlight certain mitigating strengths.

Our study has limitations. While our population included diverse national representation, the response rate and demographics of our respondents may limit generalizability beyond our study population. Respondents represented multiple perspectives within the HM hiring process and were not limited to those making the final hiring decisions. For questions with prespecified multiple-choice answers, answer choices may have influenced participant responses. Our conclusions are based on the reported preferences of those involved in the HM hiring process and not actual hiring behavior. Future research should attempt to identify factors (eg, region, graduate medical education status, practice setting type) that may be responsible for some of the heterogeneous themes we observed in our analysis.

Our research represents introductory work into the previously unpublished topic of HM-specific hiring practices. These findings may provide relevant insight for trainees considering careers in HM, hospitalists reentering the job market, and those involved in career advising, professional development and the HM hiring process.

Acknowledgments

The authors would like to acknowledge current and former members of SHM’s Physicians in Training Committee whose feedback and leadership helped to inspire this project, as well as those students, residents, and hospitalists who have participated in our Hospital Medicine Annual Meeting interview workshop.

Disclosures

The authors have no conflicts of interest to disclose.

Hospital Medicine (HM) is medicine’s fastest growing specialty.¹ Rapid expansion of the field has been met with rising interest by young physicians, many of whom are first-time job seekers and may desire information on best practices for applying and interviewing in HM.^2-4 However, no prior work has examined HM-specific candidate qualifications and qualities that may be most valued in the hiring process.

As members of the Society of Hospital Medicine (SHM) Physicians in Training Committee, a group charged with “prepar[ing] trainees and early career hospitalists in their transition into hospital medicine,” we aimed to fill this knowledge gap around the HM-specific hiring process.

Survey Instrument

The authors developed the survey based on expertise as HM interviewers (JAD, AH, CD, EE, BK, DS, and SM) and local and national interview workshop leaders (JAD, CD, BK, SM). The questionnaire focused on objective applicant qualifications, qualities and attributes displayed during interviews (Appendix 1). Content, length, and reliability of physician understanding were assessed via feedback from local HM group leaders.

Respondents were asked to provide nonidentifying demographics and their role in their HM group’s hiring process. If they reported no role, the survey was terminated. Subsequent standardized HM group demographic questions were adapted from the Society of Hospital Medicine (SHM) State of Hospital Medicine Report.⁵

Survey questions were multiple choice, ranking and free-response aimed at understanding how respondents assess HM candidate attributes, skills, and behavior. For ranking questions, answer choice order was randomized to reduce answer order-based bias. One free-response question asked the respondent to provide a unique interview question they use that “reveals the most about a hospitalist candidate.” Responses were then individually inserted into the list of choices for a subsequent ranking question regarding the most important qualities a candidate must demonstrate.

Respondents were asked four open-ended questions designed to understand the approach to candidate assessment: (1) use of unique interview questions (as above); (2) identification of “red flags” during interviews; (3) distinctions between assessment of long-term (LT) career hospitalist candidates versus short-term (ST) candidates (eg, those seeking positions prior to fellowship); and (4) key qualifications of ST candidates.

Survey Administration

Survey recipients were identified via SHM administrative rosters. Surveys were distributed electronically via SHM to all current nontrainee physician members who reported a United States mailing address. The survey was determined to not constitute human subjects research by the Beth Israel Deaconess Medical Center Committee on Clinical Investigations.

Data Analysis

Multiple-choice responses were analyzed descriptively. For ranking-type questions, answers were weighted based on ranking order.

Responses to all open-ended survey questions were analyzed using thematic analysis. We used an iterative process to develop and refine codes identifying key concepts that emerged from the data. Three authors independently coded survey responses. As a group, research team members established the coding framework and resolved discrepancies via discussion to achieve consensus.

Survey links were sent to 8,398 e-mail addresses, of which 7,306 were undeliverable or unopened, leaving 1,092 total eligible respondents. Of these, 347 (31.8%) responded.

A total of 236 respondents reported having a formal role in HM hiring. Of these roles, 79.0% were one-on-one interviewers, 49.6% group interviewers, 45.5% telephone/videoconference interviewers, 41.5% participated on a selection committee, and 32.1% identified as the ultimate decision-maker. Regarding graduate medical education teaching status, 42.0% of respondents identified their primary workplace as a community/affiliated teaching hospital, 33.05% as a university-based teaching hospital, and 23.0% as a nonteaching hospital. Additional characteristics are reported in Appendix 2.

Quantitative Analysis

Respondents ranked the top five qualifications of HM candidates and the top five qualities a candidate should demonstrate on the interview day to be considered for hiring (Table 1).

When asked to rate agreement with the statement “I evaluate and consider all hospital medicine candidates similarly, regardless of whether they articulate an interest in hospital medicine as a long-term career or as a short-term position before fellowship,” 99 (57.23%) respondents disagreed.

Qualitative Analysis

Thematic analysis of responses to open-ended survey questions identified several “red flag” themes (Table 2). Negative interactions with current providers or staff were commonly noted. Additional red flags were a lack of knowledge or interest in the specific HM group, an inability to articulate career goals, or abnormalities in employment history or application materials. Respondents identified an overly strong focus on lifestyle or salary as factors that might limit a candidate’s chance of advancing in the hiring process.

Responses to free-text questions additionally highlighted preferred questioning techniques and approaches to HM candidate assessment (Appendix 3). Many interview questions addressed candidate interest in a particular HM program and candidate responses to challenging scenarios they had encountered. Other questions explored career development. Respondents wanted LT candidates to have specific HM career goals, while they expected ST candidates to demonstrate commitment to and appreciation of HM as a discipline.

Some respondents described their approach to candidate assessment in terms of investment and risk. LT candidates were often viewed as investments in stability and performance; they were evaluated on current abilities and future potential as related to group-specific goals. Some respondents viewed hiring ST candidates as more risky given concerns that they might be less engaged or integrated with the group. Others viewed the hiring of LT candidates as comparably more risky, relating the longer time commitment to the potential for higher impact on the group and patient care. Accordingly, these respondents viewed ST candidate hiring as less risky, estimating their shorter time commitment as having less of a positive or negative impact, with the benefit of addressing urgent staffing issues or unfilled less desirable positions. One respondent summarized: “If they plan to be a career candidate, I care more about them as people and future coworkers. Short term folks are great if we are in a pinch and can deal with personality issues for a short period of time.”

Respondents also described how valued candidate qualities could help mitigate the risk inherent in hiring, especially for ST hires. Strong interpersonal and teamwork skills were highlighted, as well as a demonstrated record of clinical excellence, evidenced by strong training backgrounds and superlative references. A key factor aiding in ST hiring decisions was prior knowledge of the candidate, such as residents or moonlighters previously working in the respondent’s institution. This allowed for familiarity with the candidate’s clinical acumen as well as perceived ease of onboarding and knowledge of the system.

We present the results of a national survey of hospitalists identifying candidate attributes, skills, and behaviors viewed most favorably by those involved in the HM hiring process. To our knowledge, this is the first research to be published on the topic of evaluating HM candidates.

Survey respondents identified demonstrable HM candidate clinical skills and experience as highly important, consistent with prior research identifying clinical skills as being among those that hospitalists most value.⁶ Based on these responses, job seekers should be prepared to discuss objective measures of clinical experience when appropriate, such as number of cases seen or procedures performed. HM groups may accordingly consider the use of hiring rubrics or scoring systems to standardize these measures and reduce bias.

Respondents also highly valued more subjective assessments of HM applicants’ candidacy. The most highly ranked action item was a candidate’s ability to meaningfully respond to a respondent’s customized interview question. There was also a preference for candidates who were knowledgeable about and interested in the specifics of a particular HM group. The high value placed on these elements may suggest the need for formalized coaching or interview preparation for HM candidates. Similarly, interviewer emphasis on customized questions may also highlight an opportunity for HM groups to internally standardize how to best approach subjective components of the interview.

Our heterogeneous findings on the distinctions between ST and LT candidate hiring practices support the need for additional research on the ST HM job market. Until then, our findings reinforce the importance of applicant transparency about ST versus LT career goals. Although many programs may prefer LT candidates over ST candidates, our results suggest ST candidates may benefit from targeting groups with ST needs and using the application process as an opportunity to highlight certain mitigating strengths.

Our study has limitations. While our population included diverse national representation, the response rate and demographics of our respondents may limit generalizability beyond our study population. Respondents represented multiple perspectives within the HM hiring process and were not limited to those making the final hiring decisions. For questions with prespecified multiple-choice answers, answer choices may have influenced participant responses. Our conclusions are based on the reported preferences of those involved in the HM hiring process and not actual hiring behavior. Future research should attempt to identify factors (eg, region, graduate medical education status, practice setting type) that may be responsible for some of the heterogeneous themes we observed in our analysis.

Our research represents introductory work into the previously unpublished topic of HM-specific hiring practices. These findings may provide relevant insight for trainees considering careers in HM, hospitalists reentering the job market, and those involved in career advising, professional development and the HM hiring process.

Acknowledgments

The authors would like to acknowledge current and former members of SHM’s Physicians in Training Committee whose feedback and leadership helped to inspire this project, as well as those students, residents, and hospitalists who have participated in our Hospital Medicine Annual Meeting interview workshop.

Disclosures

The authors have no conflicts of interest to disclose.

Hospital Medicine (HM) is medicine’s fastest growing specialty.¹ Rapid expansion of the field has been met with rising interest by young physicians, many of whom are first-time job seekers and may desire information on best practices for applying and interviewing in HM.^2-4 However, no prior work has examined HM-specific candidate qualifications and qualities that may be most valued in the hiring process.

As members of the Society of Hospital Medicine (SHM) Physicians in Training Committee, a group charged with “prepar[ing] trainees and early career hospitalists in their transition into hospital medicine,” we aimed to fill this knowledge gap around the HM-specific hiring process.

Survey Instrument

The authors developed the survey based on expertise as HM interviewers (JAD, AH, CD, EE, BK, DS, and SM) and local and national interview workshop leaders (JAD, CD, BK, SM). The questionnaire focused on objective applicant qualifications, qualities and attributes displayed during interviews (Appendix 1). Content, length, and reliability of physician understanding were assessed via feedback from local HM group leaders.

Respondents were asked to provide nonidentifying demographics and their role in their HM group’s hiring process. If they reported no role, the survey was terminated. Subsequent standardized HM group demographic questions were adapted from the Society of Hospital Medicine (SHM) State of Hospital Medicine Report.⁵

Survey questions were multiple choice, ranking and free-response aimed at understanding how respondents assess HM candidate attributes, skills, and behavior. For ranking questions, answer choice order was randomized to reduce answer order-based bias. One free-response question asked the respondent to provide a unique interview question they use that “reveals the most about a hospitalist candidate.” Responses were then individually inserted into the list of choices for a subsequent ranking question regarding the most important qualities a candidate must demonstrate.

Respondents were asked four open-ended questions designed to understand the approach to candidate assessment: (1) use of unique interview questions (as above); (2) identification of “red flags” during interviews; (3) distinctions between assessment of long-term (LT) career hospitalist candidates versus short-term (ST) candidates (eg, those seeking positions prior to fellowship); and (4) key qualifications of ST candidates.

Survey Administration

Survey recipients were identified via SHM administrative rosters. Surveys were distributed electronically via SHM to all current nontrainee physician members who reported a United States mailing address. The survey was determined to not constitute human subjects research by the Beth Israel Deaconess Medical Center Committee on Clinical Investigations.

Data Analysis

Multiple-choice responses were analyzed descriptively. For ranking-type questions, answers were weighted based on ranking order.

Responses to all open-ended survey questions were analyzed using thematic analysis. We used an iterative process to develop and refine codes identifying key concepts that emerged from the data. Three authors independently coded survey responses. As a group, research team members established the coding framework and resolved discrepancies via discussion to achieve consensus.

Survey links were sent to 8,398 e-mail addresses, of which 7,306 were undeliverable or unopened, leaving 1,092 total eligible respondents. Of these, 347 (31.8%) responded.

A total of 236 respondents reported having a formal role in HM hiring. Of these roles, 79.0% were one-on-one interviewers, 49.6% group interviewers, 45.5% telephone/videoconference interviewers, 41.5% participated on a selection committee, and 32.1% identified as the ultimate decision-maker. Regarding graduate medical education teaching status, 42.0% of respondents identified their primary workplace as a community/affiliated teaching hospital, 33.05% as a university-based teaching hospital, and 23.0% as a nonteaching hospital. Additional characteristics are reported in Appendix 2.

Quantitative Analysis

Respondents ranked the top five qualifications of HM candidates and the top five qualities a candidate should demonstrate on the interview day to be considered for hiring (Table 1).

When asked to rate agreement with the statement “I evaluate and consider all hospital medicine candidates similarly, regardless of whether they articulate an interest in hospital medicine as a long-term career or as a short-term position before fellowship,” 99 (57.23%) respondents disagreed.

Qualitative Analysis

Thematic analysis of responses to open-ended survey questions identified several “red flag” themes (Table 2). Negative interactions with current providers or staff were commonly noted. Additional red flags were a lack of knowledge or interest in the specific HM group, an inability to articulate career goals, or abnormalities in employment history or application materials. Respondents identified an overly strong focus on lifestyle or salary as factors that might limit a candidate’s chance of advancing in the hiring process.

Responses to free-text questions additionally highlighted preferred questioning techniques and approaches to HM candidate assessment (Appendix 3). Many interview questions addressed candidate interest in a particular HM program and candidate responses to challenging scenarios they had encountered. Other questions explored career development. Respondents wanted LT candidates to have specific HM career goals, while they expected ST candidates to demonstrate commitment to and appreciation of HM as a discipline.

Some respondents described their approach to candidate assessment in terms of investment and risk. LT candidates were often viewed as investments in stability and performance; they were evaluated on current abilities and future potential as related to group-specific goals. Some respondents viewed hiring ST candidates as more risky given concerns that they might be less engaged or integrated with the group. Others viewed the hiring of LT candidates as comparably more risky, relating the longer time commitment to the potential for higher impact on the group and patient care. Accordingly, these respondents viewed ST candidate hiring as less risky, estimating their shorter time commitment as having less of a positive or negative impact, with the benefit of addressing urgent staffing issues or unfilled less desirable positions. One respondent summarized: “If they plan to be a career candidate, I care more about them as people and future coworkers. Short term folks are great if we are in a pinch and can deal with personality issues for a short period of time.”

Respondents also described how valued candidate qualities could help mitigate the risk inherent in hiring, especially for ST hires. Strong interpersonal and teamwork skills were highlighted, as well as a demonstrated record of clinical excellence, evidenced by strong training backgrounds and superlative references. A key factor aiding in ST hiring decisions was prior knowledge of the candidate, such as residents or moonlighters previously working in the respondent’s institution. This allowed for familiarity with the candidate’s clinical acumen as well as perceived ease of onboarding and knowledge of the system.

We present the results of a national survey of hospitalists identifying candidate attributes, skills, and behaviors viewed most favorably by those involved in the HM hiring process. To our knowledge, this is the first research to be published on the topic of evaluating HM candidates.

Survey respondents identified demonstrable HM candidate clinical skills and experience as highly important, consistent with prior research identifying clinical skills as being among those that hospitalists most value.⁶ Based on these responses, job seekers should be prepared to discuss objective measures of clinical experience when appropriate, such as number of cases seen or procedures performed. HM groups may accordingly consider the use of hiring rubrics or scoring systems to standardize these measures and reduce bias.

Respondents also highly valued more subjective assessments of HM applicants’ candidacy. The most highly ranked action item was a candidate’s ability to meaningfully respond to a respondent’s customized interview question. There was also a preference for candidates who were knowledgeable about and interested in the specifics of a particular HM group. The high value placed on these elements may suggest the need for formalized coaching or interview preparation for HM candidates. Similarly, interviewer emphasis on customized questions may also highlight an opportunity for HM groups to internally standardize how to best approach subjective components of the interview.

Our heterogeneous findings on the distinctions between ST and LT candidate hiring practices support the need for additional research on the ST HM job market. Until then, our findings reinforce the importance of applicant transparency about ST versus LT career goals. Although many programs may prefer LT candidates over ST candidates, our results suggest ST candidates may benefit from targeting groups with ST needs and using the application process as an opportunity to highlight certain mitigating strengths.

Our study has limitations. While our population included diverse national representation, the response rate and demographics of our respondents may limit generalizability beyond our study population. Respondents represented multiple perspectives within the HM hiring process and were not limited to those making the final hiring decisions. For questions with prespecified multiple-choice answers, answer choices may have influenced participant responses. Our conclusions are based on the reported preferences of those involved in the HM hiring process and not actual hiring behavior. Future research should attempt to identify factors (eg, region, graduate medical education status, practice setting type) that may be responsible for some of the heterogeneous themes we observed in our analysis.

Our research represents introductory work into the previously unpublished topic of HM-specific hiring practices. These findings may provide relevant insight for trainees considering careers in HM, hospitalists reentering the job market, and those involved in career advising, professional development and the HM hiring process.

Acknowledgments

The authors would like to acknowledge current and former members of SHM’s Physicians in Training Committee whose feedback and leadership helped to inspire this project, as well as those students, residents, and hospitalists who have participated in our Hospital Medicine Annual Meeting interview workshop.

Disclosures

The authors have no conflicts of interest to disclose.

Delivering feedback is a fundamental skill in medicine. Feedback ensures trainees remain on track to meet expected goals and standards. At some point in our careers, all of us have been on the receiving end of feedback. Many of us have likely had the opportunity to provide feedback to students or junior residents during our training. Moving from the role of trainee to supervisor presents a unique set of challenges and responsibilities to the young hospitalist.

Despite an extensive amount published on feedback, translation from theory to practice remains challenging.1 When surveyed, medical students and residents commonly perceive they do not receive enough feedback.2 Conversely, attendees of faculty development courses frequently indicate their greatest need is learning how to give feedback more effectively.3 Why does this performance gap exist?

The Issues

Careful exploration of our current training model reveals several systemic barriers to effective feedback. For one, many faculty members who supervise trainees are not formally trained educators. As such, they may lack the proper skills set to deliver feedback.1 Additionally, lack of time is often cited in the pressure to complete both clinical and academic duties within a packed workday. If learners aren’t directly observed by their supervisors, the impact and quality of feedback substantially diminishes.4 Likewise, if feedback is not embedded in the local culture and expected by both educator and learner, it can be perceived as a burden rather than a valuable exercise.

Feedback can evoke deep, sometimes subconscious emotional responses in both supervisor and recipient. During verbal interactions with trainees, dialogue tends to assume positive or neutral tones regardless of content.5 To avoid bruising a young learner’s ego, a well-intentioned educator may talk around the actual problem, using indirect statements in an attempt to “soften the blow.” Fearing a negative evaluation, the student may support and reinforce the teacher’s avoidance, further obscuring the message being sent. This concept is known as “vanishing feedback” and is a common barrier to the delivery of effective feedback.4 Educators additionally may shy away from giving constructive feedback because they fear reprisal on teaching evaluations.

Mounting evidence shows physicians, as a whole, tend to overestimate their abilities, and many are not skilled at self-assessment.6 When physician-learners receive feedback incongruent with their own self-perceptions, it may trigger feelings of anger, sadness, guilt, or self-doubt, which may block the receipt of any useful information. The so-called “millennial generation effect,” describing current medical school graduates, may further compound this issue. Millennials are “raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback.”1,5 As such, certain learners may intentionally avoid feedback as a method of self-preservation.

A New Approach

Many of us were taught to use the “feedback sandwich,” in which two positive statements surround a single negative corrective comment. This model, however, has some notable weaknesses. Given the ratio of positive to negative statements, educators may concentrate too heavily on the positive, diluting any constructive criticism and leaving learners with a false impression. Alternatively, trainees may learn to ignore positive comments while waiting for the other shoe to drop. As such, any initial positivity may feel insincere and artificial.7

Instead, we advocate using the “reflective feedback conversation,” a model that begins with self-assessment and places the onus on learners to identify their strengths and weaknesses.7 For example, a trainee might remark, “I struggle with controlling my temper when I am stressed.” The educator might reinforce that comment by stating, “I noticed you raised your voice last week when talking with the nurse because she forgot to administer Lasix.” To conclude the conversation, the teacher and student discuss shared goal setting and mutually agree on future improvements. Notably, this model does not facilitate conversation about problems a learner fails to detect. Hence, the educator must be prepared to deliver feedback outside of the learner’s own assessment.

Here are our favorite tips and tricks for delivering effective feedback:

1. Establish a positive learning climate. Educators must partner with learners to generate an atmosphere of mutual trust and respect.1,3,4,8 An example of how to ally with learners is to announce early on, “As a teacher, I really value feedback. As such, I plan on giving feedback throughout the rotation because I want you to be the best doctor you can possibly be.”
2. Require reflection. Effective feedback hinges on learners’ ability to self-assess.2,5,7 One approach is starting each feedback session with a simple open-ended question, such as, “How do you think you are doing?” Alternatively, you could be more specific, such as, “How do you think you did in managing the patient’s electrolytes when he went into diabetic ketoacidosis?”
3. Be prompt. Feedback should be timely.1,4,7,8 An important distinction between feedback and evaluation is that feedback is formative, enabling learners to make needed changes before the end of a course, whereas evaluation is summative and presents a distinct judgment.1,4 If feedback is withheld until the end of the rotation, learners will not have an opportunity to remediate behaviors.
4. Take advantage of different formats. Try a brief, concrete suggestion on the fly. A statement that might occur on bedside rounds is, “Allow me to show you a better technique to measure the liver span.” Or use a teachable event, such as a medical error or a particularly challenging case. Pulling interns aside after they deliver sobering news is a great opportunity to provide feedback in a semiformal fashion. Finally, formal sit-down feedback should be scheduled halfway through each rotation to ensure learners are on track and to address any major issues, such as professionalism or an inadequate clinical performance.2
5. Be specific. Focus on behaviors and examples rather than judgments.1,2,4,7,8 For example, we have all experienced the inattentive student. Instead of framing feedback as, “It seems like you don’t care about medicine because you weren’t paying attention on rounds,” one could say, “I noticed you were fidgeting and looking at your phone during Aaron’s presentation.” Feedback should be based on firsthand observations and should be descriptive, utilizing neutral language.
6. Avoid information overload. Feedback is best consumed in small snacks rather than an all-you-can-eat buffet.1,7 Your goal should not be to completely overhaul a learner but rather to focus on a few observable, correctable behaviors.
7. Be empathetic. To make negative feedback less threatening, take yourself off the pedestal. An example of this could be saying, “As a third-year medical student, I struggled to remember all the right questions to ask, so performing a thorough review of systems helped me to catch the things I would miss.”
8. Confirm understanding. It is important to know the learner has heard the feedback and to conclude the session with an action plan.

Just as hospitals engage in continuous quality improvement, as professionals, we should all strive for continuous self-improvement. Giving and receiving feedback is critical to personal growth. It is our hope that by using these tips, all of us will improve, creating a new generation of providers who give effective and useful feedback.

References

1. Anderson PA. Giving feedback on clinical skills: are we starving our young? J Grad Med Educ. 2012;4(2):154-158. doi:10.4300/JGME-D-11-000295.1.
2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002;77(12 Pt 1):1185-1188.
3. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med. 1998;13(2):111-116.
4. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
5. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009;302(12):1330-1331.
6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-1102.
7. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008;337:a1961.
8. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791.

Delivering feedback is a fundamental skill in medicine. Feedback ensures trainees remain on track to meet expected goals and standards. At some point in our careers, all of us have been on the receiving end of feedback. Many of us have likely had the opportunity to provide feedback to students or junior residents during our training. Moving from the role of trainee to supervisor presents a unique set of challenges and responsibilities to the young hospitalist.

Despite an extensive amount published on feedback, translation from theory to practice remains challenging.1 When surveyed, medical students and residents commonly perceive they do not receive enough feedback.2 Conversely, attendees of faculty development courses frequently indicate their greatest need is learning how to give feedback more effectively.3 Why does this performance gap exist?

The Issues

Careful exploration of our current training model reveals several systemic barriers to effective feedback. For one, many faculty members who supervise trainees are not formally trained educators. As such, they may lack the proper skills set to deliver feedback.1 Additionally, lack of time is often cited in the pressure to complete both clinical and academic duties within a packed workday. If learners aren’t directly observed by their supervisors, the impact and quality of feedback substantially diminishes.4 Likewise, if feedback is not embedded in the local culture and expected by both educator and learner, it can be perceived as a burden rather than a valuable exercise.

Feedback can evoke deep, sometimes subconscious emotional responses in both supervisor and recipient. During verbal interactions with trainees, dialogue tends to assume positive or neutral tones regardless of content.5 To avoid bruising a young learner’s ego, a well-intentioned educator may talk around the actual problem, using indirect statements in an attempt to “soften the blow.” Fearing a negative evaluation, the student may support and reinforce the teacher’s avoidance, further obscuring the message being sent. This concept is known as “vanishing feedback” and is a common barrier to the delivery of effective feedback.4 Educators additionally may shy away from giving constructive feedback because they fear reprisal on teaching evaluations.

Mounting evidence shows physicians, as a whole, tend to overestimate their abilities, and many are not skilled at self-assessment.6 When physician-learners receive feedback incongruent with their own self-perceptions, it may trigger feelings of anger, sadness, guilt, or self-doubt, which may block the receipt of any useful information. The so-called “millennial generation effect,” describing current medical school graduates, may further compound this issue. Millennials are “raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback.”1,5 As such, certain learners may intentionally avoid feedback as a method of self-preservation.

A New Approach

Many of us were taught to use the “feedback sandwich,” in which two positive statements surround a single negative corrective comment. This model, however, has some notable weaknesses. Given the ratio of positive to negative statements, educators may concentrate too heavily on the positive, diluting any constructive criticism and leaving learners with a false impression. Alternatively, trainees may learn to ignore positive comments while waiting for the other shoe to drop. As such, any initial positivity may feel insincere and artificial.7

Instead, we advocate using the “reflective feedback conversation,” a model that begins with self-assessment and places the onus on learners to identify their strengths and weaknesses.7 For example, a trainee might remark, “I struggle with controlling my temper when I am stressed.” The educator might reinforce that comment by stating, “I noticed you raised your voice last week when talking with the nurse because she forgot to administer Lasix.” To conclude the conversation, the teacher and student discuss shared goal setting and mutually agree on future improvements. Notably, this model does not facilitate conversation about problems a learner fails to detect. Hence, the educator must be prepared to deliver feedback outside of the learner’s own assessment.

Here are our favorite tips and tricks for delivering effective feedback:

1. Establish a positive learning climate. Educators must partner with learners to generate an atmosphere of mutual trust and respect.1,3,4,8 An example of how to ally with learners is to announce early on, “As a teacher, I really value feedback. As such, I plan on giving feedback throughout the rotation because I want you to be the best doctor you can possibly be.”
2. Require reflection. Effective feedback hinges on learners’ ability to self-assess.2,5,7 One approach is starting each feedback session with a simple open-ended question, such as, “How do you think you are doing?” Alternatively, you could be more specific, such as, “How do you think you did in managing the patient’s electrolytes when he went into diabetic ketoacidosis?”
3. Be prompt. Feedback should be timely.1,4,7,8 An important distinction between feedback and evaluation is that feedback is formative, enabling learners to make needed changes before the end of a course, whereas evaluation is summative and presents a distinct judgment.1,4 If feedback is withheld until the end of the rotation, learners will not have an opportunity to remediate behaviors.
4. Take advantage of different formats. Try a brief, concrete suggestion on the fly. A statement that might occur on bedside rounds is, “Allow me to show you a better technique to measure the liver span.” Or use a teachable event, such as a medical error or a particularly challenging case. Pulling interns aside after they deliver sobering news is a great opportunity to provide feedback in a semiformal fashion. Finally, formal sit-down feedback should be scheduled halfway through each rotation to ensure learners are on track and to address any major issues, such as professionalism or an inadequate clinical performance.2
5. Be specific. Focus on behaviors and examples rather than judgments.1,2,4,7,8 For example, we have all experienced the inattentive student. Instead of framing feedback as, “It seems like you don’t care about medicine because you weren’t paying attention on rounds,” one could say, “I noticed you were fidgeting and looking at your phone during Aaron’s presentation.” Feedback should be based on firsthand observations and should be descriptive, utilizing neutral language.
6. Avoid information overload. Feedback is best consumed in small snacks rather than an all-you-can-eat buffet.1,7 Your goal should not be to completely overhaul a learner but rather to focus on a few observable, correctable behaviors.
7. Be empathetic. To make negative feedback less threatening, take yourself off the pedestal. An example of this could be saying, “As a third-year medical student, I struggled to remember all the right questions to ask, so performing a thorough review of systems helped me to catch the things I would miss.”
8. Confirm understanding. It is important to know the learner has heard the feedback and to conclude the session with an action plan.

Just as hospitals engage in continuous quality improvement, as professionals, we should all strive for continuous self-improvement. Giving and receiving feedback is critical to personal growth. It is our hope that by using these tips, all of us will improve, creating a new generation of providers who give effective and useful feedback.

References

1. Anderson PA. Giving feedback on clinical skills: are we starving our young? J Grad Med Educ. 2012;4(2):154-158. doi:10.4300/JGME-D-11-000295.1.
2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002;77(12 Pt 1):1185-1188.
3. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med. 1998;13(2):111-116.
4. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
5. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009;302(12):1330-1331.
6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-1102.
7. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008;337:a1961.
8. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791.

Delivering feedback is a fundamental skill in medicine. Feedback ensures trainees remain on track to meet expected goals and standards. At some point in our careers, all of us have been on the receiving end of feedback. Many of us have likely had the opportunity to provide feedback to students or junior residents during our training. Moving from the role of trainee to supervisor presents a unique set of challenges and responsibilities to the young hospitalist.

Despite an extensive amount published on feedback, translation from theory to practice remains challenging.1 When surveyed, medical students and residents commonly perceive they do not receive enough feedback.2 Conversely, attendees of faculty development courses frequently indicate their greatest need is learning how to give feedback more effectively.3 Why does this performance gap exist?

The Issues

Careful exploration of our current training model reveals several systemic barriers to effective feedback. For one, many faculty members who supervise trainees are not formally trained educators. As such, they may lack the proper skills set to deliver feedback.1 Additionally, lack of time is often cited in the pressure to complete both clinical and academic duties within a packed workday. If learners aren’t directly observed by their supervisors, the impact and quality of feedback substantially diminishes.4 Likewise, if feedback is not embedded in the local culture and expected by both educator and learner, it can be perceived as a burden rather than a valuable exercise.

Feedback can evoke deep, sometimes subconscious emotional responses in both supervisor and recipient. During verbal interactions with trainees, dialogue tends to assume positive or neutral tones regardless of content.5 To avoid bruising a young learner’s ego, a well-intentioned educator may talk around the actual problem, using indirect statements in an attempt to “soften the blow.” Fearing a negative evaluation, the student may support and reinforce the teacher’s avoidance, further obscuring the message being sent. This concept is known as “vanishing feedback” and is a common barrier to the delivery of effective feedback.4 Educators additionally may shy away from giving constructive feedback because they fear reprisal on teaching evaluations.

Mounting evidence shows physicians, as a whole, tend to overestimate their abilities, and many are not skilled at self-assessment.6 When physician-learners receive feedback incongruent with their own self-perceptions, it may trigger feelings of anger, sadness, guilt, or self-doubt, which may block the receipt of any useful information. The so-called “millennial generation effect,” describing current medical school graduates, may further compound this issue. Millennials are “raised with an emphasis on being special; a previous absence of a balanced focus on weakness may present a barrier to accepting the validity of negative feedback.”1,5 As such, certain learners may intentionally avoid feedback as a method of self-preservation.

A New Approach

Many of us were taught to use the “feedback sandwich,” in which two positive statements surround a single negative corrective comment. This model, however, has some notable weaknesses. Given the ratio of positive to negative statements, educators may concentrate too heavily on the positive, diluting any constructive criticism and leaving learners with a false impression. Alternatively, trainees may learn to ignore positive comments while waiting for the other shoe to drop. As such, any initial positivity may feel insincere and artificial.7

Instead, we advocate using the “reflective feedback conversation,” a model that begins with self-assessment and places the onus on learners to identify their strengths and weaknesses.7 For example, a trainee might remark, “I struggle with controlling my temper when I am stressed.” The educator might reinforce that comment by stating, “I noticed you raised your voice last week when talking with the nurse because she forgot to administer Lasix.” To conclude the conversation, the teacher and student discuss shared goal setting and mutually agree on future improvements. Notably, this model does not facilitate conversation about problems a learner fails to detect. Hence, the educator must be prepared to deliver feedback outside of the learner’s own assessment.

Here are our favorite tips and tricks for delivering effective feedback:

1. Establish a positive learning climate. Educators must partner with learners to generate an atmosphere of mutual trust and respect.1,3,4,8 An example of how to ally with learners is to announce early on, “As a teacher, I really value feedback. As such, I plan on giving feedback throughout the rotation because I want you to be the best doctor you can possibly be.”
2. Require reflection. Effective feedback hinges on learners’ ability to self-assess.2,5,7 One approach is starting each feedback session with a simple open-ended question, such as, “How do you think you are doing?” Alternatively, you could be more specific, such as, “How do you think you did in managing the patient’s electrolytes when he went into diabetic ketoacidosis?”
3. Be prompt. Feedback should be timely.1,4,7,8 An important distinction between feedback and evaluation is that feedback is formative, enabling learners to make needed changes before the end of a course, whereas evaluation is summative and presents a distinct judgment.1,4 If feedback is withheld until the end of the rotation, learners will not have an opportunity to remediate behaviors.
4. Take advantage of different formats. Try a brief, concrete suggestion on the fly. A statement that might occur on bedside rounds is, “Allow me to show you a better technique to measure the liver span.” Or use a teachable event, such as a medical error or a particularly challenging case. Pulling interns aside after they deliver sobering news is a great opportunity to provide feedback in a semiformal fashion. Finally, formal sit-down feedback should be scheduled halfway through each rotation to ensure learners are on track and to address any major issues, such as professionalism or an inadequate clinical performance.2
5. Be specific. Focus on behaviors and examples rather than judgments.1,2,4,7,8 For example, we have all experienced the inattentive student. Instead of framing feedback as, “It seems like you don’t care about medicine because you weren’t paying attention on rounds,” one could say, “I noticed you were fidgeting and looking at your phone during Aaron’s presentation.” Feedback should be based on firsthand observations and should be descriptive, utilizing neutral language.
6. Avoid information overload. Feedback is best consumed in small snacks rather than an all-you-can-eat buffet.1,7 Your goal should not be to completely overhaul a learner but rather to focus on a few observable, correctable behaviors.
7. Be empathetic. To make negative feedback less threatening, take yourself off the pedestal. An example of this could be saying, “As a third-year medical student, I struggled to remember all the right questions to ask, so performing a thorough review of systems helped me to catch the things I would miss.”
8. Confirm understanding. It is important to know the learner has heard the feedback and to conclude the session with an action plan.

Just as hospitals engage in continuous quality improvement, as professionals, we should all strive for continuous self-improvement. Giving and receiving feedback is critical to personal growth. It is our hope that by using these tips, all of us will improve, creating a new generation of providers who give effective and useful feedback.

References

1. Anderson PA. Giving feedback on clinical skills: are we starving our young? J Grad Med Educ. 2012;4(2):154-158. doi:10.4300/JGME-D-11-000295.1.
2. Branch WT, Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med. 2002;77(12 Pt 1):1185-1188.
3. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med. 1998;13(2):111-116.
4. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
5. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009;302(12):1330-1331.
6. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-1102.
7. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ. 2008;337:a1961.
8. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791.