Emily Gottenborg, MD

“Knowing yourself is the beginning of all wisdom.”—Aristotle

On the wards, your white coat and stethoscope signal your role as a healthcare provider. These external symbols of your work represent your expertise, experience, and commitment to service, and your patients look to these signals for comfort and reassurance. But when you are running a meeting, managing projects, or leading people in your organization, how do others know what you have to offer? Although signaling your values, skills, and intentions is as important in leadership as it is in the clinical setting, few clinicians spend time reflecting on how best to do this. Crafting a strong, consistent personal leadership brand can help.

As described by Norm Smallwood and Dave Ulrich, a personal leadership brand is the external projection of your strengths and interests, which demonstrates how you create value for others.^1,2 In other words, a personal leadership brand helps constituents, stakeholders, and potential partners understand what you offer as a leader. Having a brand keeps you on track as a leader and helps get you noticed for future opportunities by helping you shape and meet expectations in a way that is deliberate, dynamic, and authentic.

Building your personal leadership brand is an exercise in reflection. Leaders should challenge themselves to answer the following questions:

• What do I have to offer, and what do others appreciate about me?
• What are my values?
• Where am I trying to go?
• How does my path align with organizational goals?

The answers to these simple questions can help you create your personal leadership brand. First, reflect on what you want to be known for, your values, and how you are currently perceived. Then, identify the results you are aiming to produce, aligning them with your strengths and organizational goals. Write these down, and share your reflections with trusted peers and your mentoring team. Shape your thoughts into a personal vision statement with a focus on what you put out into the world to help you stay true to yourself while producing the desired results. For example, a vision statement for a gifted communicator with a background in quality improvement may be: “I will use my strong communication skills to address complex problems impacting our hospital to reduce cost and improve quality with the goal of building a career as a health system leader.” Finally, be authentic, and share your personal brand in an articulate and succinct way to help others understand your place in the structure and narrative of an organization.

Your personal leadership brand should not be static; rather, it is a process that should iterate over time. Ask for direct feedback from trusted advisers and allies at regular intervals. Investigate whether your organization offers a formal structure, such as a “360 Evaluation,” to get perspective on how your unique strengths, skills, and goals are perceived. Then, explore and clarify discrepancies between where you think you are and how others see you. Approaching these conversations with humility will keep you aligned with your values, which makes it easier for others to be invested in your development.

A strong personal leadership brand is a force multiplier, providing clarity within teams and helping align a leader’s assets and values with organizational goals. It is a solid external signal of what others can expect from your work and will help you focus on your strengths while identifying areas for growth. A personal leadership brand is formed through reflection and, at its core, its authenticity. In the words of Paracelsus, a Renaissance physician, astrologer, and alchemist, “Be not another, if you can be yourself.”³

“Knowing yourself is the beginning of all wisdom.”—Aristotle

On the wards, your white coat and stethoscope signal your role as a healthcare provider. These external symbols of your work represent your expertise, experience, and commitment to service, and your patients look to these signals for comfort and reassurance. But when you are running a meeting, managing projects, or leading people in your organization, how do others know what you have to offer? Although signaling your values, skills, and intentions is as important in leadership as it is in the clinical setting, few clinicians spend time reflecting on how best to do this. Crafting a strong, consistent personal leadership brand can help.

As described by Norm Smallwood and Dave Ulrich, a personal leadership brand is the external projection of your strengths and interests, which demonstrates how you create value for others.^1,2 In other words, a personal leadership brand helps constituents, stakeholders, and potential partners understand what you offer as a leader. Having a brand keeps you on track as a leader and helps get you noticed for future opportunities by helping you shape and meet expectations in a way that is deliberate, dynamic, and authentic.

Building your personal leadership brand is an exercise in reflection. Leaders should challenge themselves to answer the following questions:

• What do I have to offer, and what do others appreciate about me?
• What are my values?
• Where am I trying to go?
• How does my path align with organizational goals?

The answers to these simple questions can help you create your personal leadership brand. First, reflect on what you want to be known for, your values, and how you are currently perceived. Then, identify the results you are aiming to produce, aligning them with your strengths and organizational goals. Write these down, and share your reflections with trusted peers and your mentoring team. Shape your thoughts into a personal vision statement with a focus on what you put out into the world to help you stay true to yourself while producing the desired results. For example, a vision statement for a gifted communicator with a background in quality improvement may be: “I will use my strong communication skills to address complex problems impacting our hospital to reduce cost and improve quality with the goal of building a career as a health system leader.” Finally, be authentic, and share your personal brand in an articulate and succinct way to help others understand your place in the structure and narrative of an organization.

Your personal leadership brand should not be static; rather, it is a process that should iterate over time. Ask for direct feedback from trusted advisers and allies at regular intervals. Investigate whether your organization offers a formal structure, such as a “360 Evaluation,” to get perspective on how your unique strengths, skills, and goals are perceived. Then, explore and clarify discrepancies between where you think you are and how others see you. Approaching these conversations with humility will keep you aligned with your values, which makes it easier for others to be invested in your development.

A strong personal leadership brand is a force multiplier, providing clarity within teams and helping align a leader’s assets and values with organizational goals. It is a solid external signal of what others can expect from your work and will help you focus on your strengths while identifying areas for growth. A personal leadership brand is formed through reflection and, at its core, its authenticity. In the words of Paracelsus, a Renaissance physician, astrologer, and alchemist, “Be not another, if you can be yourself.”³

“Knowing yourself is the beginning of all wisdom.”—Aristotle

On the wards, your white coat and stethoscope signal your role as a healthcare provider. These external symbols of your work represent your expertise, experience, and commitment to service, and your patients look to these signals for comfort and reassurance. But when you are running a meeting, managing projects, or leading people in your organization, how do others know what you have to offer? Although signaling your values, skills, and intentions is as important in leadership as it is in the clinical setting, few clinicians spend time reflecting on how best to do this. Crafting a strong, consistent personal leadership brand can help.

As described by Norm Smallwood and Dave Ulrich, a personal leadership brand is the external projection of your strengths and interests, which demonstrates how you create value for others.^1,2 In other words, a personal leadership brand helps constituents, stakeholders, and potential partners understand what you offer as a leader. Having a brand keeps you on track as a leader and helps get you noticed for future opportunities by helping you shape and meet expectations in a way that is deliberate, dynamic, and authentic.

Building your personal leadership brand is an exercise in reflection. Leaders should challenge themselves to answer the following questions:

• What do I have to offer, and what do others appreciate about me?
• What are my values?
• Where am I trying to go?
• How does my path align with organizational goals?

The answers to these simple questions can help you create your personal leadership brand. First, reflect on what you want to be known for, your values, and how you are currently perceived. Then, identify the results you are aiming to produce, aligning them with your strengths and organizational goals. Write these down, and share your reflections with trusted peers and your mentoring team. Shape your thoughts into a personal vision statement with a focus on what you put out into the world to help you stay true to yourself while producing the desired results. For example, a vision statement for a gifted communicator with a background in quality improvement may be: “I will use my strong communication skills to address complex problems impacting our hospital to reduce cost and improve quality with the goal of building a career as a health system leader.” Finally, be authentic, and share your personal brand in an articulate and succinct way to help others understand your place in the structure and narrative of an organization.

Your personal leadership brand should not be static; rather, it is a process that should iterate over time. Ask for direct feedback from trusted advisers and allies at regular intervals. Investigate whether your organization offers a formal structure, such as a “360 Evaluation,” to get perspective on how your unique strengths, skills, and goals are perceived. Then, explore and clarify discrepancies between where you think you are and how others see you. Approaching these conversations with humility will keep you aligned with your values, which makes it easier for others to be invested in your development.

A strong personal leadership brand is a force multiplier, providing clarity within teams and helping align a leader’s assets and values with organizational goals. It is a solid external signal of what others can expect from your work and will help you focus on your strengths while identifying areas for growth. A personal leadership brand is formed through reflection and, at its core, its authenticity. In the words of Paracelsus, a Renaissance physician, astrologer, and alchemist, “Be not another, if you can be yourself.”³

As fall arrives, new interns are rapidly gaining clinical confidence, and residency recruitment season is ramping up. It’s also time to announce the opening of the SHM Student Hospitalist Scholar Grant Program applications; we are now recruiting our sixth group of scholars for the summer and longitudinal programs.

Doctors_two_talking_web.jpg

Since its creation in 2015, the grant has supported 23 students in this incredible opportunity to allow trainees to engage in scholarly work with guidance from a mentor to better understand the practice of hospital medicine and to further grow our robust pipeline.

The 2018-2019 cohort of scholars, Matthew Fallon, Philip Huang, and Erin Rainosek, just concluded their projects and are currently preparing their abstracts for submission for Hospital Medicine 2020, where there is a track for Early-Career Hospitalists. The projects targeted a diverse set of domains, including improving upon the patient experience, readmission quality metrics, geographic cohorting, and clinical documentation integrity – all highly relevant topics for a practicing hospitalist.

Matthew Fallon collaborated with his mentor, Dr. Venkata Andukuri, at Creighton University, to reduce the rate of hospital readmission for patients with heart failure, by analyzing retrospective data in a root cause analysis to identify factors that influence readmission rate, then targeting those directly. They also integrated the patient experience by seeking out patient input as to the challenges they face in the management of their heart failure.

Philip Huang worked with his mentor, Dr. Ethan Kuperman, at the Carver College of Medicine, University of Iowa, to improve geographic localization for hospitalized patients to improve care efficiency. They worked closely with an industrial engineering team to create a workflow model integrated into the hospital EHR to designate patient location and were able to better understand the role that other professions play in improving the health care delivery.

Finally, Erin Rainosek teamed up with her mentor, Dr. Luci Leykum, at the University of Texas Health Science Center at San Antonio, to apply a design thinking strategy to redesign the health care experience for hospitalized patients. She engaged in over 120 hours of patient interviews and ultimately identified key themes that impact the experience of care, which will serve as target areas moving forward.

The student scholars in this cohort gained significant insight into the patient experience and quality issues relevant to the field of hospital medicine. We are proud of their accomplishments and look forward to their future successes and careers in hospital medicine. If you would like to learn more about the experience of our scholars this past summer, they have posted full write-ups on the Future Hospitalist RoundUp blog in HMX, SHM’s online community.

For students interested in becoming scholars, SHM offers two options to eligible medical students – the Summer Program and the Longitudinal Program. Both programs allow students to participate in projects related to quality improvement, patient safety, clinical research or hospital operations, in order to learn more about career paths in hospital medicine. Students will have the opportunity to conduct scholarly work with a mentor in these domains, with the option of participating over the summer during a 6-10-week period or longitudinally throughout the course of a year.

Discover additional benefits and how to apply on the SHM website. Applications will close in late January 2020.

Dr. Gottenborg is director of the Hospitalist Training Program within the Internal Medicine Residency Program at the University of Colorado. Dr. Duckett is assistant professor of medicine at the Medical University of South Carolina.

As fall arrives, new interns are rapidly gaining clinical confidence, and residency recruitment season is ramping up. It’s also time to announce the opening of the SHM Student Hospitalist Scholar Grant Program applications; we are now recruiting our sixth group of scholars for the summer and longitudinal programs.

Doctors_two_talking_web.jpg

Since its creation in 2015, the grant has supported 23 students in this incredible opportunity to allow trainees to engage in scholarly work with guidance from a mentor to better understand the practice of hospital medicine and to further grow our robust pipeline.

The 2018-2019 cohort of scholars, Matthew Fallon, Philip Huang, and Erin Rainosek, just concluded their projects and are currently preparing their abstracts for submission for Hospital Medicine 2020, where there is a track for Early-Career Hospitalists. The projects targeted a diverse set of domains, including improving upon the patient experience, readmission quality metrics, geographic cohorting, and clinical documentation integrity – all highly relevant topics for a practicing hospitalist.

Matthew Fallon collaborated with his mentor, Dr. Venkata Andukuri, at Creighton University, to reduce the rate of hospital readmission for patients with heart failure, by analyzing retrospective data in a root cause analysis to identify factors that influence readmission rate, then targeting those directly. They also integrated the patient experience by seeking out patient input as to the challenges they face in the management of their heart failure.

Philip Huang worked with his mentor, Dr. Ethan Kuperman, at the Carver College of Medicine, University of Iowa, to improve geographic localization for hospitalized patients to improve care efficiency. They worked closely with an industrial engineering team to create a workflow model integrated into the hospital EHR to designate patient location and were able to better understand the role that other professions play in improving the health care delivery.

Finally, Erin Rainosek teamed up with her mentor, Dr. Luci Leykum, at the University of Texas Health Science Center at San Antonio, to apply a design thinking strategy to redesign the health care experience for hospitalized patients. She engaged in over 120 hours of patient interviews and ultimately identified key themes that impact the experience of care, which will serve as target areas moving forward.

The student scholars in this cohort gained significant insight into the patient experience and quality issues relevant to the field of hospital medicine. We are proud of their accomplishments and look forward to their future successes and careers in hospital medicine. If you would like to learn more about the experience of our scholars this past summer, they have posted full write-ups on the Future Hospitalist RoundUp blog in HMX, SHM’s online community.

For students interested in becoming scholars, SHM offers two options to eligible medical students – the Summer Program and the Longitudinal Program. Both programs allow students to participate in projects related to quality improvement, patient safety, clinical research or hospital operations, in order to learn more about career paths in hospital medicine. Students will have the opportunity to conduct scholarly work with a mentor in these domains, with the option of participating over the summer during a 6-10-week period or longitudinally throughout the course of a year.

Discover additional benefits and how to apply on the SHM website. Applications will close in late January 2020.

Dr. Gottenborg is director of the Hospitalist Training Program within the Internal Medicine Residency Program at the University of Colorado. Dr. Duckett is assistant professor of medicine at the Medical University of South Carolina.

As fall arrives, new interns are rapidly gaining clinical confidence, and residency recruitment season is ramping up. It’s also time to announce the opening of the SHM Student Hospitalist Scholar Grant Program applications; we are now recruiting our sixth group of scholars for the summer and longitudinal programs.

Doctors_two_talking_web.jpg

Since its creation in 2015, the grant has supported 23 students in this incredible opportunity to allow trainees to engage in scholarly work with guidance from a mentor to better understand the practice of hospital medicine and to further grow our robust pipeline.

The 2018-2019 cohort of scholars, Matthew Fallon, Philip Huang, and Erin Rainosek, just concluded their projects and are currently preparing their abstracts for submission for Hospital Medicine 2020, where there is a track for Early-Career Hospitalists. The projects targeted a diverse set of domains, including improving upon the patient experience, readmission quality metrics, geographic cohorting, and clinical documentation integrity – all highly relevant topics for a practicing hospitalist.

Matthew Fallon collaborated with his mentor, Dr. Venkata Andukuri, at Creighton University, to reduce the rate of hospital readmission for patients with heart failure, by analyzing retrospective data in a root cause analysis to identify factors that influence readmission rate, then targeting those directly. They also integrated the patient experience by seeking out patient input as to the challenges they face in the management of their heart failure.

Philip Huang worked with his mentor, Dr. Ethan Kuperman, at the Carver College of Medicine, University of Iowa, to improve geographic localization for hospitalized patients to improve care efficiency. They worked closely with an industrial engineering team to create a workflow model integrated into the hospital EHR to designate patient location and were able to better understand the role that other professions play in improving the health care delivery.

Finally, Erin Rainosek teamed up with her mentor, Dr. Luci Leykum, at the University of Texas Health Science Center at San Antonio, to apply a design thinking strategy to redesign the health care experience for hospitalized patients. She engaged in over 120 hours of patient interviews and ultimately identified key themes that impact the experience of care, which will serve as target areas moving forward.

The student scholars in this cohort gained significant insight into the patient experience and quality issues relevant to the field of hospital medicine. We are proud of their accomplishments and look forward to their future successes and careers in hospital medicine. If you would like to learn more about the experience of our scholars this past summer, they have posted full write-ups on the Future Hospitalist RoundUp blog in HMX, SHM’s online community.

For students interested in becoming scholars, SHM offers two options to eligible medical students – the Summer Program and the Longitudinal Program. Both programs allow students to participate in projects related to quality improvement, patient safety, clinical research or hospital operations, in order to learn more about career paths in hospital medicine. Students will have the opportunity to conduct scholarly work with a mentor in these domains, with the option of participating over the summer during a 6-10-week period or longitudinally throughout the course of a year.

Discover additional benefits and how to apply on the SHM website. Applications will close in late January 2020.

Dr. Gottenborg is director of the Hospitalist Training Program within the Internal Medicine Residency Program at the University of Colorado. Dr. Duckett is assistant professor of medicine at the Medical University of South Carolina.

Anticoagulation for patients with venous thromboembolism (VTE) is associated not only with considerable benefits, including prevention of pulmonary embolus and thrombus extension, but also with potential significant risks, such as life-threatening bleeding.¹ Hospitalized patients may require anticoagulation to treat new VTE or for secondary prevention of prior events. Hospital admission is a high-risk time for anticoagulation control.² Additionally, anticoagulation has become an increasingly complex decision as the number of therapeutic agents on the market has significantly increased, coupled with medication interactions and dosing intricacies. Management is multifaceted and associated with wide variation in practice patterns.³ Thus, further evidence-based guidance for providers is necessary for the care of the hospitalized patient with VTE.

The following are 16 selected guideline recommendations most relevant to adult hospitalists.⁴ Recommendations were graded as “strong” if most individuals should follow the recommended course of action and “conditional” if different choices are appropriate for different patients.

Initial Anticoagulant Dosing, Monitoring, and Medication Interactions

(for all recommendations–evidence quality: low certainty; recommendation strength: conditional)

Recommendation 1. In obese patients receiving low molecular weight heparin (LMWH), determine the initial dose based on actual body weight rather than a fixed or “capped” maximum dose.

Recommendation 2. For obese patients or those with renal dysfunction receiving LMWH, avoid dosing based on serum antifactor Xa levels. Instead, adjust dosing based on product labeling, with appropriate dose reduction in patients with chronic kidney disease.

Recommendation 3. For patients receiving direct oral anticoagulant (DOAC) therapy, avoid measuring the anticoagulation effect during management of bleeding as there is no evidence to support a beneficial effect, and it may result in a delay in treatment.

Recommendation 4. For patients requiring administration of inhibitors or inducers of P-glycoprotein or cytochrome P450 enzymes, use LMWH or vitamin K antagonists (VKA) rather than a DOAC.

Recommendation 5. When transitioning from a DOAC to a VKA, the medications should overlap until the international normalized ratio (INR) is therapeutic instead of bridging with a heparin agent.

Recommendations for Ongoing Outpatient Monitoring upon Discharge from the Hospital

Recommendation 6. Use point-of-care INR testing by patients at home, with self-adjustment of VKA dose (evidence quality: low certainty; recommendation strength: strong).

Recommendation 7. Patients should be referred for specialized anticoagulation management rather than to their primary care provider (PCP) (evidence quality: very low certainty; recommendation strength: conditional).

Recommendation 8. Supplementary education, in addition to basic education, should be made available to patients to help improve outcomes (evidence quality: very low certainty; recommendation strength: conditional).

Hospitalists are often responsible for the coordination of care upon discharge from the hospital, including discharge teaching, subspecialty referrals, and determination of patient suitability for home monitoring and dose adjustment. The follow-up plan may depend on local systems and access. A PCP can manage anticoagulation if performed in a systematic and coordinated fashion.⁵

Recommendations for Patients on Anticoagulation Undergoing Procedures

Recommendation 9. For patients with a low or moderate risk of recurrent VTE on VKA therapy undergoing procedures, periprocedural bridging with heparin or LMWH should be avoided. This excludes patients at high risk for recurrent VTE, defined as those with recent VTE (<3 months); having a known thrombophilic abnormality such as antiphospholipid syndrome, protein C/S deficiency, or antithrombin deficiency; or high-risk patient populations by expert consensus and practice guidelines^4,6 (evidence quality: moderate certainty; recommendation strength: strong).

Recommendation 10. For patients on DOACs undergoing procedures, measurement of the anticoagulation effect of the DOAC should be avoided (evidence quality: very low certainty; recommendation strength: conditional).

Recommendations for Patients on Anticoagulation Suffering from Supratherapeutic Levels or Bleeding Complications

(for all recommendations–evidence quality: very low certainty; recommendation strength: conditional)

Recommendation 11. If a patient on VKA therapy has an INR between 4.5 and 10 without clinically relevant bleeding, the use of vitamin K therapy can be avoided in favor of temporary cessation of VKA alone.

Recommendation 12. If a patient on VKA therapy has life-threatening bleeding, four-factor prothrombin complex concentrate (PCC) should be used in addition to the cessation of VKA therapy and initiation of vitamin K therapy, over the use of fresh frozen plaza, because of the ease of administration and minimal risk of volume overload.

Recommendation 13. If a patient has life-threatening bleeding on a Xa inhibitor, the panel recommends discontinuation of the medication and the option to administer either PCC or recombinant coagulation factor Xa, as there have been no studies comparing these two strategies.

Recommendation 14. If life-threatening bleeding occurs in a patient on dabigatran, idarucizumab should be administered, if available.

Recommendation 15. In patients with bleeding while on heparin or LMWH, protamine should be administered.

Recommendation 16. Following an episode of life-threatening bleeding, anticoagulation should be resumed within 90 days, provided that the patient is at moderate to high risk for recurrent VTE, is not at high risk for recurrent bleeding, and is willing to continue anticoagulation.

Methods in Preparing Guidelines

The panel was funded by the American Society of Hematology (ASH), a nonprofit medical specialty society.⁴ The panel is multidisciplinary, including physicians and providers as well as patient representatives, and is supported by the McMaster University GRADE Center, which conducted new and updated systematic reviews of the evidence according to the “Cochrane Handbook for Systematic Reviews of Interventions.” The panel members agreed on 25 recommendations and two good practice statements. The recommendations were made available to external review by stakeholders and addressed. Comments made by 10 individuals or organizations were subsequently incorporated.

Sources of Potential Conflict of Interest

Panel members, other than patient representatives, did not receive funding, and the majority of the panel had no conflicts of interest to report. Given the minimal influence of outside parties including pharmaceutical companies, and the wide diversity of opinions sought in the creation of the guidelines, concern for conflict of interest is low.

Generalizability

These guidelines assume that the decision to anticoagulate a patient, and which agent to use, has already been made and thus do not offer further guidance on this decision. These guidelines also do not address optimal choices for anticoagulation in specific patient populations, such as patients with cancer. They are limited in scope to exclude the treatment of specific thromboembolic disease processes such as subsegmental pulmonary emboli, superficial venous thrombus, or distal vein thrombosis. Unfortunately, challenging decisions made by hospitalists frequently fall into one of these categories. Coincident with these guidelines, ASH introduced comprehensive guidelines to support basic diagnostic decisions.⁷

More evidence is needed to better understand optimal monitoring practices for patients on anticoagulation therapy, including the ideal INR monitoring frequency for patients on VKA therapy. Additionally, there is a need to better understand the difference in clinical outcomes and resources utilization when care is provided by an anticoagulation specialist as compared with a PCP. Finally, while guidelines suggest that anticoagulation should be resumed within 90 days of a life-threatening bleed, there is a need to better understand the optimal timing of a restart, as well as the patient factors to be considered in this decision.

Disclosures

The authors have nothing to disclose.

Funding

There was no funding support in the creation of this manuscript.

Anticoagulation for patients with venous thromboembolism (VTE) is associated not only with considerable benefits, including prevention of pulmonary embolus and thrombus extension, but also with potential significant risks, such as life-threatening bleeding.¹ Hospitalized patients may require anticoagulation to treat new VTE or for secondary prevention of prior events. Hospital admission is a high-risk time for anticoagulation control.² Additionally, anticoagulation has become an increasingly complex decision as the number of therapeutic agents on the market has significantly increased, coupled with medication interactions and dosing intricacies. Management is multifaceted and associated with wide variation in practice patterns.³ Thus, further evidence-based guidance for providers is necessary for the care of the hospitalized patient with VTE.

The following are 16 selected guideline recommendations most relevant to adult hospitalists.⁴ Recommendations were graded as “strong” if most individuals should follow the recommended course of action and “conditional” if different choices are appropriate for different patients.

Initial Anticoagulant Dosing, Monitoring, and Medication Interactions

(for all recommendations–evidence quality: low certainty; recommendation strength: conditional)

Recommendation 1. In obese patients receiving low molecular weight heparin (LMWH), determine the initial dose based on actual body weight rather than a fixed or “capped” maximum dose.

Recommendation 2. For obese patients or those with renal dysfunction receiving LMWH, avoid dosing based on serum antifactor Xa levels. Instead, adjust dosing based on product labeling, with appropriate dose reduction in patients with chronic kidney disease.

Recommendation 3. For patients receiving direct oral anticoagulant (DOAC) therapy, avoid measuring the anticoagulation effect during management of bleeding as there is no evidence to support a beneficial effect, and it may result in a delay in treatment.

Recommendation 4. For patients requiring administration of inhibitors or inducers of P-glycoprotein or cytochrome P450 enzymes, use LMWH or vitamin K antagonists (VKA) rather than a DOAC.

Recommendation 5. When transitioning from a DOAC to a VKA, the medications should overlap until the international normalized ratio (INR) is therapeutic instead of bridging with a heparin agent.

Recommendations for Ongoing Outpatient Monitoring upon Discharge from the Hospital

Recommendation 6. Use point-of-care INR testing by patients at home, with self-adjustment of VKA dose (evidence quality: low certainty; recommendation strength: strong).

Recommendation 7. Patients should be referred for specialized anticoagulation management rather than to their primary care provider (PCP) (evidence quality: very low certainty; recommendation strength: conditional).

Recommendation 8. Supplementary education, in addition to basic education, should be made available to patients to help improve outcomes (evidence quality: very low certainty; recommendation strength: conditional).

Hospitalists are often responsible for the coordination of care upon discharge from the hospital, including discharge teaching, subspecialty referrals, and determination of patient suitability for home monitoring and dose adjustment. The follow-up plan may depend on local systems and access. A PCP can manage anticoagulation if performed in a systematic and coordinated fashion.⁵

Recommendations for Patients on Anticoagulation Undergoing Procedures

Recommendation 9. For patients with a low or moderate risk of recurrent VTE on VKA therapy undergoing procedures, periprocedural bridging with heparin or LMWH should be avoided. This excludes patients at high risk for recurrent VTE, defined as those with recent VTE (<3 months); having a known thrombophilic abnormality such as antiphospholipid syndrome, protein C/S deficiency, or antithrombin deficiency; or high-risk patient populations by expert consensus and practice guidelines^4,6 (evidence quality: moderate certainty; recommendation strength: strong).

Recommendation 10. For patients on DOACs undergoing procedures, measurement of the anticoagulation effect of the DOAC should be avoided (evidence quality: very low certainty; recommendation strength: conditional).

Recommendations for Patients on Anticoagulation Suffering from Supratherapeutic Levels or Bleeding Complications

(for all recommendations–evidence quality: very low certainty; recommendation strength: conditional)

Recommendation 11. If a patient on VKA therapy has an INR between 4.5 and 10 without clinically relevant bleeding, the use of vitamin K therapy can be avoided in favor of temporary cessation of VKA alone.

Recommendation 12. If a patient on VKA therapy has life-threatening bleeding, four-factor prothrombin complex concentrate (PCC) should be used in addition to the cessation of VKA therapy and initiation of vitamin K therapy, over the use of fresh frozen plaza, because of the ease of administration and minimal risk of volume overload.

Recommendation 13. If a patient has life-threatening bleeding on a Xa inhibitor, the panel recommends discontinuation of the medication and the option to administer either PCC or recombinant coagulation factor Xa, as there have been no studies comparing these two strategies.

Recommendation 14. If life-threatening bleeding occurs in a patient on dabigatran, idarucizumab should be administered, if available.

Recommendation 15. In patients with bleeding while on heparin or LMWH, protamine should be administered.

Recommendation 16. Following an episode of life-threatening bleeding, anticoagulation should be resumed within 90 days, provided that the patient is at moderate to high risk for recurrent VTE, is not at high risk for recurrent bleeding, and is willing to continue anticoagulation.

Methods in Preparing Guidelines

The panel was funded by the American Society of Hematology (ASH), a nonprofit medical specialty society.⁴ The panel is multidisciplinary, including physicians and providers as well as patient representatives, and is supported by the McMaster University GRADE Center, which conducted new and updated systematic reviews of the evidence according to the “Cochrane Handbook for Systematic Reviews of Interventions.” The panel members agreed on 25 recommendations and two good practice statements. The recommendations were made available to external review by stakeholders and addressed. Comments made by 10 individuals or organizations were subsequently incorporated.

Sources of Potential Conflict of Interest

Panel members, other than patient representatives, did not receive funding, and the majority of the panel had no conflicts of interest to report. Given the minimal influence of outside parties including pharmaceutical companies, and the wide diversity of opinions sought in the creation of the guidelines, concern for conflict of interest is low.

Generalizability

These guidelines assume that the decision to anticoagulate a patient, and which agent to use, has already been made and thus do not offer further guidance on this decision. These guidelines also do not address optimal choices for anticoagulation in specific patient populations, such as patients with cancer. They are limited in scope to exclude the treatment of specific thromboembolic disease processes such as subsegmental pulmonary emboli, superficial venous thrombus, or distal vein thrombosis. Unfortunately, challenging decisions made by hospitalists frequently fall into one of these categories. Coincident with these guidelines, ASH introduced comprehensive guidelines to support basic diagnostic decisions.⁷

More evidence is needed to better understand optimal monitoring practices for patients on anticoagulation therapy, including the ideal INR monitoring frequency for patients on VKA therapy. Additionally, there is a need to better understand the difference in clinical outcomes and resources utilization when care is provided by an anticoagulation specialist as compared with a PCP. Finally, while guidelines suggest that anticoagulation should be resumed within 90 days of a life-threatening bleed, there is a need to better understand the optimal timing of a restart, as well as the patient factors to be considered in this decision.

Disclosures

The authors have nothing to disclose.

Funding

There was no funding support in the creation of this manuscript.

Anticoagulation for patients with venous thromboembolism (VTE) is associated not only with considerable benefits, including prevention of pulmonary embolus and thrombus extension, but also with potential significant risks, such as life-threatening bleeding.¹ Hospitalized patients may require anticoagulation to treat new VTE or for secondary prevention of prior events. Hospital admission is a high-risk time for anticoagulation control.² Additionally, anticoagulation has become an increasingly complex decision as the number of therapeutic agents on the market has significantly increased, coupled with medication interactions and dosing intricacies. Management is multifaceted and associated with wide variation in practice patterns.³ Thus, further evidence-based guidance for providers is necessary for the care of the hospitalized patient with VTE.

The following are 16 selected guideline recommendations most relevant to adult hospitalists.⁴ Recommendations were graded as “strong” if most individuals should follow the recommended course of action and “conditional” if different choices are appropriate for different patients.

Initial Anticoagulant Dosing, Monitoring, and Medication Interactions

(for all recommendations–evidence quality: low certainty; recommendation strength: conditional)

Recommendation 1. In obese patients receiving low molecular weight heparin (LMWH), determine the initial dose based on actual body weight rather than a fixed or “capped” maximum dose.

Recommendation 2. For obese patients or those with renal dysfunction receiving LMWH, avoid dosing based on serum antifactor Xa levels. Instead, adjust dosing based on product labeling, with appropriate dose reduction in patients with chronic kidney disease.

Recommendation 3. For patients receiving direct oral anticoagulant (DOAC) therapy, avoid measuring the anticoagulation effect during management of bleeding as there is no evidence to support a beneficial effect, and it may result in a delay in treatment.

Recommendation 4. For patients requiring administration of inhibitors or inducers of P-glycoprotein or cytochrome P450 enzymes, use LMWH or vitamin K antagonists (VKA) rather than a DOAC.

Recommendation 5. When transitioning from a DOAC to a VKA, the medications should overlap until the international normalized ratio (INR) is therapeutic instead of bridging with a heparin agent.

Recommendations for Ongoing Outpatient Monitoring upon Discharge from the Hospital

Recommendation 6. Use point-of-care INR testing by patients at home, with self-adjustment of VKA dose (evidence quality: low certainty; recommendation strength: strong).

Recommendation 7. Patients should be referred for specialized anticoagulation management rather than to their primary care provider (PCP) (evidence quality: very low certainty; recommendation strength: conditional).

Recommendation 8. Supplementary education, in addition to basic education, should be made available to patients to help improve outcomes (evidence quality: very low certainty; recommendation strength: conditional).

Hospitalists are often responsible for the coordination of care upon discharge from the hospital, including discharge teaching, subspecialty referrals, and determination of patient suitability for home monitoring and dose adjustment. The follow-up plan may depend on local systems and access. A PCP can manage anticoagulation if performed in a systematic and coordinated fashion.⁵

Recommendations for Patients on Anticoagulation Undergoing Procedures

Recommendation 9. For patients with a low or moderate risk of recurrent VTE on VKA therapy undergoing procedures, periprocedural bridging with heparin or LMWH should be avoided. This excludes patients at high risk for recurrent VTE, defined as those with recent VTE (<3 months); having a known thrombophilic abnormality such as antiphospholipid syndrome, protein C/S deficiency, or antithrombin deficiency; or high-risk patient populations by expert consensus and practice guidelines^4,6 (evidence quality: moderate certainty; recommendation strength: strong).

Recommendation 10. For patients on DOACs undergoing procedures, measurement of the anticoagulation effect of the DOAC should be avoided (evidence quality: very low certainty; recommendation strength: conditional).

Recommendations for Patients on Anticoagulation Suffering from Supratherapeutic Levels or Bleeding Complications

(for all recommendations–evidence quality: very low certainty; recommendation strength: conditional)

Recommendation 11. If a patient on VKA therapy has an INR between 4.5 and 10 without clinically relevant bleeding, the use of vitamin K therapy can be avoided in favor of temporary cessation of VKA alone.

Recommendation 12. If a patient on VKA therapy has life-threatening bleeding, four-factor prothrombin complex concentrate (PCC) should be used in addition to the cessation of VKA therapy and initiation of vitamin K therapy, over the use of fresh frozen plaza, because of the ease of administration and minimal risk of volume overload.

Recommendation 13. If a patient has life-threatening bleeding on a Xa inhibitor, the panel recommends discontinuation of the medication and the option to administer either PCC or recombinant coagulation factor Xa, as there have been no studies comparing these two strategies.

Recommendation 14. If life-threatening bleeding occurs in a patient on dabigatran, idarucizumab should be administered, if available.

Recommendation 15. In patients with bleeding while on heparin or LMWH, protamine should be administered.

Recommendation 16. Following an episode of life-threatening bleeding, anticoagulation should be resumed within 90 days, provided that the patient is at moderate to high risk for recurrent VTE, is not at high risk for recurrent bleeding, and is willing to continue anticoagulation.

Methods in Preparing Guidelines

The panel was funded by the American Society of Hematology (ASH), a nonprofit medical specialty society.⁴ The panel is multidisciplinary, including physicians and providers as well as patient representatives, and is supported by the McMaster University GRADE Center, which conducted new and updated systematic reviews of the evidence according to the “Cochrane Handbook for Systematic Reviews of Interventions.” The panel members agreed on 25 recommendations and two good practice statements. The recommendations were made available to external review by stakeholders and addressed. Comments made by 10 individuals or organizations were subsequently incorporated.

Sources of Potential Conflict of Interest

Panel members, other than patient representatives, did not receive funding, and the majority of the panel had no conflicts of interest to report. Given the minimal influence of outside parties including pharmaceutical companies, and the wide diversity of opinions sought in the creation of the guidelines, concern for conflict of interest is low.

Generalizability

These guidelines assume that the decision to anticoagulate a patient, and which agent to use, has already been made and thus do not offer further guidance on this decision. These guidelines also do not address optimal choices for anticoagulation in specific patient populations, such as patients with cancer. They are limited in scope to exclude the treatment of specific thromboembolic disease processes such as subsegmental pulmonary emboli, superficial venous thrombus, or distal vein thrombosis. Unfortunately, challenging decisions made by hospitalists frequently fall into one of these categories. Coincident with these guidelines, ASH introduced comprehensive guidelines to support basic diagnostic decisions.⁷

More evidence is needed to better understand optimal monitoring practices for patients on anticoagulation therapy, including the ideal INR monitoring frequency for patients on VKA therapy. Additionally, there is a need to better understand the difference in clinical outcomes and resources utilization when care is provided by an anticoagulation specialist as compared with a PCP. Finally, while guidelines suggest that anticoagulation should be resumed within 90 days of a life-threatening bleed, there is a need to better understand the optimal timing of a restart, as well as the patient factors to be considered in this decision.

Disclosures

The authors have nothing to disclose.

Funding

There was no funding support in the creation of this manuscript.

Hospitalized patients often receive intravenous fluids (IVF) when they cannot meet physiologic needs through oral intake in the setting of medical or surgical illness. Prescribing the optimal IVF solution to the appropriate patient is a complex decision and often occurs without the same degree of institutionalized restrictions or guidance developed for other inpatient pharmacologic agents. There is wide variation in clinical utilization of IVF due to the lack of data to guide decision making.¹ When data do exist, they typically focus on a limited number of clinical situations.² Thus, even though IVF are often considered low-risk, the frequency and lack of consistency with which they are used can result in errors, complications, and over-use of medical resources.³

(Evidence quality: not described in the guideline, recommendation strength: not described in the guideline)

Recommendation 1

To aid in fluid management and avoid complications, the guidelines recommend that patients on IVF require careful assessment of volume status, including a detailed history, physical exam, clinical monitoring, and daily labs.²

Clinical history should focus on understanding fluid losses and intake; physical exam should include vital signs, evidence of orthostatic hypotension, capillary refill, jugular venous pulsation, and assessment for pulmonary edema. Subsequent clinical monitoring should include fluid balance (Ins and Outs) and daily weights. All patients starting or continuing IVF should have a basic metabolic panel at least daily according to the guidelines, though the authors note this frequency may be too high for some patients and needs further study.²

Recommendation 2

The guidelines describe four types of IV fluids that can be administered: crystalloids, balanced crystalloids, glucose solutions, and non blood-product colloids.²

Crystalloids include isotonic saline with 154 millimoles (mmol) of sodium and chloride. Balanced crystalloids, such as lactated Ringer’s solution, are more physiologic, with less sodium and chloride, and the addition of magnesium, potassium, and calcium. Glucose solutions are quickly metabolized and, thus, are an effective way to deliver free water. Non blood-product colloids include particles that are retained within the circulation, including proteins such as human albumin.

Recommendation 3

For each indication to administer IVF, the guidelines recommend the following formulations and considerations:²

For general resuscitation, use crystalloids with sodium content of 130-154 mmol, delivered in a bolus of at least 500 milliliters (mL) over 15 minutes or less. For sepsis, infuse at least 30 mL/kg.⁴ For routine maintenance, restrict the volume to 25-30 mL/kg/day of water, and include 1 mmol/kg/day of potassium, sodium, and chloride along with 50-100 g/day of glucose to prevent starvation ketosis, though glucose should be avoided in most diabetic patients. With obesity, adjust the IVF to ideal body weight, and for patients who are older, frail, or admitted with renal or cardiac impairment, consider prescribing a lower range of fluid (20-25 mL/kg/day). For redistribution or replacement, use sodium chloride or balanced crystalloids or consider colloids, which have a theoretical advantage in expanding intravascular volume while limiting interstitial edema. Note that colloids are more expensive, and definitive evidence supporting increased efficacy is lacking. Clinicians should monitor closely for hypovolemia, hypervolemia, and electrolyte abnormalities, particularly hypo- and hypernatremia that carry associated mental status implications and risk of central pontine myelinolysis. The inadvertent overuse of IVF is common in hospital settings, particularly when maintenance fluids are not discontinued upon patient improvement or when patients move between care areas. Thus, regular clinical reassessment of volume status is important.

Recommendation 4

In both noncritically ill and critically ill hospitalized patients, there is a benefit to using balanced crystalloids compared to isotonic saline in preventing major adverse kidney events and death.^5,6

Two important studies in 2018 added new information to the existing NICE guidelines, addressing the previously unanswered question of the benefits of balanced crystalloids versus isotonic saline, one among non-critically ill patients and the other among critically ill patients.^5,6 Prior data suggested that the use of isotonic saline is associated with multiple complications, including hyperchloremic metabolic acidosis, acute kidney injury, and death. In the non-critically ill population, the use of balanced crystalloids resulted in lower incidence of major adverse kidney events (absolute difference of 0.9%), but did not change the number of hospital days (the primary outcome).⁵ In the critically ill population the use of balanced crystalloids resulted in lower rates of death, new renal replacement therapy, or persistent renal dysfunction,⁶ and the authors found preferential use of balanced crystalloids could prevent one out of every 94 patients admitted to the ICU from experiencing these adverse outcomes. Given the similar cost associated with isotonic saline and balanced crystalloids, these new findings suggest hospitalists should select balanced crystalloids if there is no compelling clinical reason to use isotonic saline.

While conflicts of interest are often a concern in clinical guidelines due to influence by pharmaceutical, device, and specialty interests, the United Kingdom’s National Clinical Guideline Centre (NGC), which developed the NICE guidelines, is hosted by the Royal College of Physicians and has governance partnerships with the Royal College of Surgeons of England, Royal College of General Practitioners, and Royal College of Nursing. Each guideline produced by the NGC is overseen by an independent guideline committee comprised of healthcare professionals and patient representatives, and as a result, concern for conflicts of interest is low.

The NICE guidelines were created by a multidisciplinary team from multiple clinical specialties, and reviewed evidence addressing both clinical and health economic outcomes. Importantly, data from randomized controlled studies was relatively limited. The data excluded patients under 16 years of age, pregnant women, and those with severe liver or renal disease, diabetes or burns, as well as those in intensive care settings. Unfortunately, many medical patients cared for by hospitalists fall into one or more of these categories, limiting applicability of the guidelines.

Two important studies in 2018 added new information to the existing NICE guidelines, as outlined in Recommendation 4.^5,6 Both of these studies occurred at a single institution, limiting their generalizability, though each study included a diverse patient population. In the ICU study, treating clinicians were aware of the composition of the assigned crystalloid so the decision to initiate renal-replacement therapy may have been susceptible to treatment bias. In addition, censoring of data collection at hospital discharge may have underestimated the true incidence of death at 30 days and overestimated persistent renal dysfunction at 30 days. Importantly, the trial design did not allow comparison of lactated Ringer’s solution versus Plasma-Lyte. The non-ICU study evaluated patients who began treatment in the emergency department and were subsequently admitted to non-ICU inpatient units—a population that mirrors much of hospitalist practice, however the un-blinded design makes bias a concern. Finally, lactated Ringer’s solution represented more than 95% of the balanced crystalloids used in the trial, so additional study is required to compare Plasma-Lyte with both saline and lactated Ringer’s solution.

More evidence is needed to better understand the appropriate use of IVF in specific clinical scenarios, including to determine if balanced solutions, as compared with isotonic saline, are superior across a spectrum of clinical conditions. For patients with an indication for maintenance fluid administration, determining if a higher sodium content reduces the risk of hyponatremia without increasing the risk of volume overload will help guide practice. Finally, more comprehensive study of the incidence of overuse and complications as a consequence of IVF, as well as the optimal frequency of lab monitoring, is needed to guide understanding of how practicing hospitalists and health systems can help reduce harm and waste

Disclosures

The authors have nothing to disclose.

Hospitalized patients often receive intravenous fluids (IVF) when they cannot meet physiologic needs through oral intake in the setting of medical or surgical illness. Prescribing the optimal IVF solution to the appropriate patient is a complex decision and often occurs without the same degree of institutionalized restrictions or guidance developed for other inpatient pharmacologic agents. There is wide variation in clinical utilization of IVF due to the lack of data to guide decision making.¹ When data do exist, they typically focus on a limited number of clinical situations.² Thus, even though IVF are often considered low-risk, the frequency and lack of consistency with which they are used can result in errors, complications, and over-use of medical resources.³

(Evidence quality: not described in the guideline, recommendation strength: not described in the guideline)

Recommendation 1

To aid in fluid management and avoid complications, the guidelines recommend that patients on IVF require careful assessment of volume status, including a detailed history, physical exam, clinical monitoring, and daily labs.²

Clinical history should focus on understanding fluid losses and intake; physical exam should include vital signs, evidence of orthostatic hypotension, capillary refill, jugular venous pulsation, and assessment for pulmonary edema. Subsequent clinical monitoring should include fluid balance (Ins and Outs) and daily weights. All patients starting or continuing IVF should have a basic metabolic panel at least daily according to the guidelines, though the authors note this frequency may be too high for some patients and needs further study.²

Recommendation 2

The guidelines describe four types of IV fluids that can be administered: crystalloids, balanced crystalloids, glucose solutions, and non blood-product colloids.²

Crystalloids include isotonic saline with 154 millimoles (mmol) of sodium and chloride. Balanced crystalloids, such as lactated Ringer’s solution, are more physiologic, with less sodium and chloride, and the addition of magnesium, potassium, and calcium. Glucose solutions are quickly metabolized and, thus, are an effective way to deliver free water. Non blood-product colloids include particles that are retained within the circulation, including proteins such as human albumin.

Recommendation 3

For each indication to administer IVF, the guidelines recommend the following formulations and considerations:²

For general resuscitation, use crystalloids with sodium content of 130-154 mmol, delivered in a bolus of at least 500 milliliters (mL) over 15 minutes or less. For sepsis, infuse at least 30 mL/kg.⁴ For routine maintenance, restrict the volume to 25-30 mL/kg/day of water, and include 1 mmol/kg/day of potassium, sodium, and chloride along with 50-100 g/day of glucose to prevent starvation ketosis, though glucose should be avoided in most diabetic patients. With obesity, adjust the IVF to ideal body weight, and for patients who are older, frail, or admitted with renal or cardiac impairment, consider prescribing a lower range of fluid (20-25 mL/kg/day). For redistribution or replacement, use sodium chloride or balanced crystalloids or consider colloids, which have a theoretical advantage in expanding intravascular volume while limiting interstitial edema. Note that colloids are more expensive, and definitive evidence supporting increased efficacy is lacking. Clinicians should monitor closely for hypovolemia, hypervolemia, and electrolyte abnormalities, particularly hypo- and hypernatremia that carry associated mental status implications and risk of central pontine myelinolysis. The inadvertent overuse of IVF is common in hospital settings, particularly when maintenance fluids are not discontinued upon patient improvement or when patients move between care areas. Thus, regular clinical reassessment of volume status is important.

Recommendation 4

In both noncritically ill and critically ill hospitalized patients, there is a benefit to using balanced crystalloids compared to isotonic saline in preventing major adverse kidney events and death.^5,6

Two important studies in 2018 added new information to the existing NICE guidelines, addressing the previously unanswered question of the benefits of balanced crystalloids versus isotonic saline, one among non-critically ill patients and the other among critically ill patients.^5,6 Prior data suggested that the use of isotonic saline is associated with multiple complications, including hyperchloremic metabolic acidosis, acute kidney injury, and death. In the non-critically ill population, the use of balanced crystalloids resulted in lower incidence of major adverse kidney events (absolute difference of 0.9%), but did not change the number of hospital days (the primary outcome).⁵ In the critically ill population the use of balanced crystalloids resulted in lower rates of death, new renal replacement therapy, or persistent renal dysfunction,⁶ and the authors found preferential use of balanced crystalloids could prevent one out of every 94 patients admitted to the ICU from experiencing these adverse outcomes. Given the similar cost associated with isotonic saline and balanced crystalloids, these new findings suggest hospitalists should select balanced crystalloids if there is no compelling clinical reason to use isotonic saline.

While conflicts of interest are often a concern in clinical guidelines due to influence by pharmaceutical, device, and specialty interests, the United Kingdom’s National Clinical Guideline Centre (NGC), which developed the NICE guidelines, is hosted by the Royal College of Physicians and has governance partnerships with the Royal College of Surgeons of England, Royal College of General Practitioners, and Royal College of Nursing. Each guideline produced by the NGC is overseen by an independent guideline committee comprised of healthcare professionals and patient representatives, and as a result, concern for conflicts of interest is low.

The NICE guidelines were created by a multidisciplinary team from multiple clinical specialties, and reviewed evidence addressing both clinical and health economic outcomes. Importantly, data from randomized controlled studies was relatively limited. The data excluded patients under 16 years of age, pregnant women, and those with severe liver or renal disease, diabetes or burns, as well as those in intensive care settings. Unfortunately, many medical patients cared for by hospitalists fall into one or more of these categories, limiting applicability of the guidelines.

Two important studies in 2018 added new information to the existing NICE guidelines, as outlined in Recommendation 4.^5,6 Both of these studies occurred at a single institution, limiting their generalizability, though each study included a diverse patient population. In the ICU study, treating clinicians were aware of the composition of the assigned crystalloid so the decision to initiate renal-replacement therapy may have been susceptible to treatment bias. In addition, censoring of data collection at hospital discharge may have underestimated the true incidence of death at 30 days and overestimated persistent renal dysfunction at 30 days. Importantly, the trial design did not allow comparison of lactated Ringer’s solution versus Plasma-Lyte. The non-ICU study evaluated patients who began treatment in the emergency department and were subsequently admitted to non-ICU inpatient units—a population that mirrors much of hospitalist practice, however the un-blinded design makes bias a concern. Finally, lactated Ringer’s solution represented more than 95% of the balanced crystalloids used in the trial, so additional study is required to compare Plasma-Lyte with both saline and lactated Ringer’s solution.

More evidence is needed to better understand the appropriate use of IVF in specific clinical scenarios, including to determine if balanced solutions, as compared with isotonic saline, are superior across a spectrum of clinical conditions. For patients with an indication for maintenance fluid administration, determining if a higher sodium content reduces the risk of hyponatremia without increasing the risk of volume overload will help guide practice. Finally, more comprehensive study of the incidence of overuse and complications as a consequence of IVF, as well as the optimal frequency of lab monitoring, is needed to guide understanding of how practicing hospitalists and health systems can help reduce harm and waste

Disclosures

The authors have nothing to disclose.

Hospitalized patients often receive intravenous fluids (IVF) when they cannot meet physiologic needs through oral intake in the setting of medical or surgical illness. Prescribing the optimal IVF solution to the appropriate patient is a complex decision and often occurs without the same degree of institutionalized restrictions or guidance developed for other inpatient pharmacologic agents. There is wide variation in clinical utilization of IVF due to the lack of data to guide decision making.¹ When data do exist, they typically focus on a limited number of clinical situations.² Thus, even though IVF are often considered low-risk, the frequency and lack of consistency with which they are used can result in errors, complications, and over-use of medical resources.³

(Evidence quality: not described in the guideline, recommendation strength: not described in the guideline)

Recommendation 1

To aid in fluid management and avoid complications, the guidelines recommend that patients on IVF require careful assessment of volume status, including a detailed history, physical exam, clinical monitoring, and daily labs.²

Clinical history should focus on understanding fluid losses and intake; physical exam should include vital signs, evidence of orthostatic hypotension, capillary refill, jugular venous pulsation, and assessment for pulmonary edema. Subsequent clinical monitoring should include fluid balance (Ins and Outs) and daily weights. All patients starting or continuing IVF should have a basic metabolic panel at least daily according to the guidelines, though the authors note this frequency may be too high for some patients and needs further study.²

Recommendation 2

The guidelines describe four types of IV fluids that can be administered: crystalloids, balanced crystalloids, glucose solutions, and non blood-product colloids.²

Crystalloids include isotonic saline with 154 millimoles (mmol) of sodium and chloride. Balanced crystalloids, such as lactated Ringer’s solution, are more physiologic, with less sodium and chloride, and the addition of magnesium, potassium, and calcium. Glucose solutions are quickly metabolized and, thus, are an effective way to deliver free water. Non blood-product colloids include particles that are retained within the circulation, including proteins such as human albumin.

Recommendation 3

For each indication to administer IVF, the guidelines recommend the following formulations and considerations:²

For general resuscitation, use crystalloids with sodium content of 130-154 mmol, delivered in a bolus of at least 500 milliliters (mL) over 15 minutes or less. For sepsis, infuse at least 30 mL/kg.⁴ For routine maintenance, restrict the volume to 25-30 mL/kg/day of water, and include 1 mmol/kg/day of potassium, sodium, and chloride along with 50-100 g/day of glucose to prevent starvation ketosis, though glucose should be avoided in most diabetic patients. With obesity, adjust the IVF to ideal body weight, and for patients who are older, frail, or admitted with renal or cardiac impairment, consider prescribing a lower range of fluid (20-25 mL/kg/day). For redistribution or replacement, use sodium chloride or balanced crystalloids or consider colloids, which have a theoretical advantage in expanding intravascular volume while limiting interstitial edema. Note that colloids are more expensive, and definitive evidence supporting increased efficacy is lacking. Clinicians should monitor closely for hypovolemia, hypervolemia, and electrolyte abnormalities, particularly hypo- and hypernatremia that carry associated mental status implications and risk of central pontine myelinolysis. The inadvertent overuse of IVF is common in hospital settings, particularly when maintenance fluids are not discontinued upon patient improvement or when patients move between care areas. Thus, regular clinical reassessment of volume status is important.

Recommendation 4

In both noncritically ill and critically ill hospitalized patients, there is a benefit to using balanced crystalloids compared to isotonic saline in preventing major adverse kidney events and death.^5,6

Two important studies in 2018 added new information to the existing NICE guidelines, addressing the previously unanswered question of the benefits of balanced crystalloids versus isotonic saline, one among non-critically ill patients and the other among critically ill patients.^5,6 Prior data suggested that the use of isotonic saline is associated with multiple complications, including hyperchloremic metabolic acidosis, acute kidney injury, and death. In the non-critically ill population, the use of balanced crystalloids resulted in lower incidence of major adverse kidney events (absolute difference of 0.9%), but did not change the number of hospital days (the primary outcome).⁵ In the critically ill population the use of balanced crystalloids resulted in lower rates of death, new renal replacement therapy, or persistent renal dysfunction,⁶ and the authors found preferential use of balanced crystalloids could prevent one out of every 94 patients admitted to the ICU from experiencing these adverse outcomes. Given the similar cost associated with isotonic saline and balanced crystalloids, these new findings suggest hospitalists should select balanced crystalloids if there is no compelling clinical reason to use isotonic saline.

While conflicts of interest are often a concern in clinical guidelines due to influence by pharmaceutical, device, and specialty interests, the United Kingdom’s National Clinical Guideline Centre (NGC), which developed the NICE guidelines, is hosted by the Royal College of Physicians and has governance partnerships with the Royal College of Surgeons of England, Royal College of General Practitioners, and Royal College of Nursing. Each guideline produced by the NGC is overseen by an independent guideline committee comprised of healthcare professionals and patient representatives, and as a result, concern for conflicts of interest is low.

The NICE guidelines were created by a multidisciplinary team from multiple clinical specialties, and reviewed evidence addressing both clinical and health economic outcomes. Importantly, data from randomized controlled studies was relatively limited. The data excluded patients under 16 years of age, pregnant women, and those with severe liver or renal disease, diabetes or burns, as well as those in intensive care settings. Unfortunately, many medical patients cared for by hospitalists fall into one or more of these categories, limiting applicability of the guidelines.

Two important studies in 2018 added new information to the existing NICE guidelines, as outlined in Recommendation 4.^5,6 Both of these studies occurred at a single institution, limiting their generalizability, though each study included a diverse patient population. In the ICU study, treating clinicians were aware of the composition of the assigned crystalloid so the decision to initiate renal-replacement therapy may have been susceptible to treatment bias. In addition, censoring of data collection at hospital discharge may have underestimated the true incidence of death at 30 days and overestimated persistent renal dysfunction at 30 days. Importantly, the trial design did not allow comparison of lactated Ringer’s solution versus Plasma-Lyte. The non-ICU study evaluated patients who began treatment in the emergency department and were subsequently admitted to non-ICU inpatient units—a population that mirrors much of hospitalist practice, however the un-blinded design makes bias a concern. Finally, lactated Ringer’s solution represented more than 95% of the balanced crystalloids used in the trial, so additional study is required to compare Plasma-Lyte with both saline and lactated Ringer’s solution.

More evidence is needed to better understand the appropriate use of IVF in specific clinical scenarios, including to determine if balanced solutions, as compared with isotonic saline, are superior across a spectrum of clinical conditions. For patients with an indication for maintenance fluid administration, determining if a higher sodium content reduces the risk of hyponatremia without increasing the risk of volume overload will help guide practice. Finally, more comprehensive study of the incidence of overuse and complications as a consequence of IVF, as well as the optimal frequency of lab monitoring, is needed to guide understanding of how practicing hospitalists and health systems can help reduce harm and waste

Disclosures

The authors have nothing to disclose.

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

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

Study Design

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

Population

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

Framework

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

Analysis

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

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

jhm013120836_t1.jpg

Paid Parental leave

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

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

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

Physical Challenges

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

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

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

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

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

Breastfeeding

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

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

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

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

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

Career Opportunities

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

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

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

Colleague Responses

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

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

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

jhm013120836_t2.jpg

Empathy in Patient Care

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

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

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

Breaking the Glass Ceiling

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

Me Too: Building Solidarity

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

Time’s Up: The Promotion Clock

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

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

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

Disclosures

The authors have no conflicts of interest to report.

Author Contributions

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

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

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

Study Design

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

Population

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

Framework

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

Analysis

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

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

jhm013120836_t1.jpg

Paid Parental leave

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

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

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

Physical Challenges

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

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

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

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

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

Breastfeeding

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

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

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

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

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

Career Opportunities

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

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

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

Colleague Responses

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

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

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

jhm013120836_t2.jpg

Empathy in Patient Care

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

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

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

Breaking the Glass Ceiling

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

Me Too: Building Solidarity

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

Time’s Up: The Promotion Clock

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

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

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

Disclosures

The authors have no conflicts of interest to report.

Author Contributions

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

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

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

Study Design

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

Population

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

Framework

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

Analysis

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

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

jhm013120836_t1.jpg

Paid Parental leave

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

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

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

Physical Challenges

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

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

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

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

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

Breastfeeding

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

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

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

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

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

Career Opportunities

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

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

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

Colleague Responses

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

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

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

jhm013120836_t2.jpg

Empathy in Patient Care

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

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

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

Breaking the Glass Ceiling

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

Me Too: Building Solidarity

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

Time’s Up: The Promotion Clock

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

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

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

Disclosures

The authors have no conflicts of interest to report.

Author Contributions

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

Editor:

Dr. Nasim Afsar’s article of June 2, 2017 (“A case for building our leadership skills”) calls for the integration of leadership skills into medical training, and we at the University of Colorado wholeheartedly agree. There are several institutions around the country that are already addressing this problem head on, and we write this letter to highlight a few educational programs we’ve created that demonstrate the power of arming our trainees with this skill set. Furthermore, we wish to encourage collaboration between educators and institutions that are engaged in similar work in the hopes of moving this field forward.

Here at the University of Colorado, a team of Hospital Medicine faculty has created a number of programs to address the leadership education gap in learners at the undergraduate medical education,¹ graduate medical education,² and fellowship levels – creating a pipeline for developing leaders in hospital medicine. These programs include an immersive medical student elective, a dedicated leadership track in the Internal Medicine Residency Program, and a fellowship program in Hospital Medicine focused on Quality Improvement and Health Systems Leadership. Our goal in each of these programs to equip trainees across the spectrum of medical education with the knowledge, attitudes, and skills needed to lead high-functioning teams.

Anstett_Tyler_Denver_Colo_Web.jpg

Tyler Anstett, DO

Manuel Diaz, MD

Emily Gottenborg, MD

University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo.

References

1. Sweigart JR, Tad-Y D, Kneeland P, Williams MV, Glasheen JJ. Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline. J Hosp Med. 2017 Mar;12(3):173-176. doi: 10.12788/jhm.2703.

2. Tad-y D, Price L, Cumbler E, Levin D, Wald H, Glasheen J. An experiential quality improvement curriculum for the inpatient setting – part 1: design phase of a QI project. MedEdPORTAL Publications. 2014;10:9841. http://doi.org/10.15766/mep_2374-8265.9841.

Editor:

Dr. Nasim Afsar’s article of June 2, 2017 (“A case for building our leadership skills”) calls for the integration of leadership skills into medical training, and we at the University of Colorado wholeheartedly agree. There are several institutions around the country that are already addressing this problem head on, and we write this letter to highlight a few educational programs we’ve created that demonstrate the power of arming our trainees with this skill set. Furthermore, we wish to encourage collaboration between educators and institutions that are engaged in similar work in the hopes of moving this field forward.

Here at the University of Colorado, a team of Hospital Medicine faculty has created a number of programs to address the leadership education gap in learners at the undergraduate medical education,¹ graduate medical education,² and fellowship levels – creating a pipeline for developing leaders in hospital medicine. These programs include an immersive medical student elective, a dedicated leadership track in the Internal Medicine Residency Program, and a fellowship program in Hospital Medicine focused on Quality Improvement and Health Systems Leadership. Our goal in each of these programs to equip trainees across the spectrum of medical education with the knowledge, attitudes, and skills needed to lead high-functioning teams.

Anstett_Tyler_Denver_Colo_Web.jpg

Tyler Anstett, DO

Manuel Diaz, MD

Emily Gottenborg, MD

University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo.

References

1. Sweigart JR, Tad-Y D, Kneeland P, Williams MV, Glasheen JJ. Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline. J Hosp Med. 2017 Mar;12(3):173-176. doi: 10.12788/jhm.2703.

2. Tad-y D, Price L, Cumbler E, Levin D, Wald H, Glasheen J. An experiential quality improvement curriculum for the inpatient setting – part 1: design phase of a QI project. MedEdPORTAL Publications. 2014;10:9841. http://doi.org/10.15766/mep_2374-8265.9841.

Editor:

Dr. Nasim Afsar’s article of June 2, 2017 (“A case for building our leadership skills”) calls for the integration of leadership skills into medical training, and we at the University of Colorado wholeheartedly agree. There are several institutions around the country that are already addressing this problem head on, and we write this letter to highlight a few educational programs we’ve created that demonstrate the power of arming our trainees with this skill set. Furthermore, we wish to encourage collaboration between educators and institutions that are engaged in similar work in the hopes of moving this field forward.

Here at the University of Colorado, a team of Hospital Medicine faculty has created a number of programs to address the leadership education gap in learners at the undergraduate medical education,¹ graduate medical education,² and fellowship levels – creating a pipeline for developing leaders in hospital medicine. These programs include an immersive medical student elective, a dedicated leadership track in the Internal Medicine Residency Program, and a fellowship program in Hospital Medicine focused on Quality Improvement and Health Systems Leadership. Our goal in each of these programs to equip trainees across the spectrum of medical education with the knowledge, attitudes, and skills needed to lead high-functioning teams.

Anstett_Tyler_Denver_Colo_Web.jpg

Tyler Anstett, DO

Manuel Diaz, MD

Emily Gottenborg, MD

University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colo.

References

1. Sweigart JR, Tad-Y D, Kneeland P, Williams MV, Glasheen JJ. Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline. J Hosp Med. 2017 Mar;12(3):173-176. doi: 10.12788/jhm.2703.

2. Tad-y D, Price L, Cumbler E, Levin D, Wald H, Glasheen J. An experiential quality improvement curriculum for the inpatient setting – part 1: design phase of a QI project. MedEdPORTAL Publications. 2014;10:9841. http://doi.org/10.15766/mep_2374-8265.9841.