The Hospitalist

Case narrative

A 35-year-old woman has worsening alcoholic cirrhosis and repeated admissions for ascites, hepato-renal syndrome, and alcoholic hepatitis. Upon recognition of her grave prognosis, we proceeded with a shared-management approach involving medicine, gastroenterology, social work, chaplaincy, and palliative care. When the team spoke with the patient’s health care proxy (HCP), family, and friends for collateral information and involvement in goals of care conversation, we realized that none were aware of her months-long decline and poor prognosis for recovery to hospital discharge.

Haddad_Nichola_MA_web.jpg

Although several factors contributed to the disconnect between the patient and her support system, the obstacles were greatly exacerbated by profound changes in hospital protocol because of the COVID-19 pandemic. Physicians feel underprepared and challenged by prognostication and discussion of end of life during normal times; we believe COVID-19 has limited this essential physician role and led to tragic delays in effective communication and end of life planning.
 

Closing the loop

For patients with complex medical issues or those reaching end of life, effective communication within the health care system is critical. While inpatient teams often drive the plan, they care for their patients during a snapshot in time; contrarily, primary care providers and specialists often have established longitudinal relationships with their patients. Ergo, clinicians should communicate directly, and ideally with both patients and families, to achieve patient-centered and goal-concordant care.

Halporn_John_MA_web.jpg

For medically complex patients, PCPs tend to prefer verbal hand-offs. Timely and reliable communication between inpatient and outpatient providers has also been shown to prevent medical adverse events.¹ Despite this, direct communication occurs infrequently.² Given that hospitalists serve as primary inpatient providers for most general admissions, it is their responsibility to communicate with outpatient providers.

A multidisciplinary team redesigned the process by which PCPs were contacted following patient discharge. The transmission of information should ideally occur prior to discharge.³ Deficits in communication are extremely common and may negatively impact patient care, patient satisfaction, and patient safety.
 

Changes during the COVID-19 era

During the pandemic, patients have only one visitor per day, restricted visiting hours, and limited interactions with clinicians per implemented policies. Along with the increased burdens from personal protective equipment, remote hospital providers (social workers, case managers), and increased bureaucratic duties, COVID-19 has elucidated limitations in medical capacity and revealed the difficulties that clinicians face in communicating with patients and families, especially about serious illness.

Barkoudah_Ebrahim_MA_web.jpg

Tasks include facilitating virtual goodbyes between dying patients and families, conducting family meetings via teleconference, and discussing patient care with specialists through virtual technologies.⁴ While these tasks are arguably more important during a global disaster, COVID-19 paradoxically restricts physical presence and severely hinders communication.⁵ Clinicians should continue to utilize core skills like building rapport, assessing patient/family perspectives and agenda, and using empathy.⁶ Patients tend to more frequently value functional outcomes while clinicians tend to default to treatment modalities.⁷ Additionally, goals of care and end of life discussions are associated with improved quality of life, fewer aggressive medical interventions near death, and even increased survival.

Given the limited resources and difficulties in communication during the pandemic, clinicians should place greater emphasis on values-based shared decision-making. Internet-based solutions are essential and widely used, and videoconferencing has been initiated at the institutional scale at many hospitals. Many clinicians with little experience are broadly implementing these technologies.⁷ Despite these technological innovations, issues still arise in how to communicate effectively in the hospital setting, and we must acknowledge that strategies require devices, Internet access, and technological literacy, highlighting disparities in access to quality health care.⁶ Conversations during the pandemic will require listening, empathy, responsive action, and the acknowledgment of the social determinants of health.⁷

Improving communication and transition of care

Multiple steps will be warranted to implement the safe transition process and improve communication. High-quality patient care encompasses careful review of medications, communication between inpatient and outpatient providers, and close follow-up at discharge. These steps serve to increase our reliance on patient compliance and the exchange of information about global progression of disease.

The quantitative and qualitative steps of transition of care should overcome disconnect between teams, specifically deficit areas regarding postdischarge communication, monitoring, and understanding of prognosis around the relevance to this era of COVID-19.
 

Dr. Haddad is a resident physician in the psychiatry residency program at Brigham and Women’s Hospital, Boston. Dr. Halporn is clinic director, Division of Adult Palliative Care, in the department of psychosocial oncology and palliative care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Dr. Barkoudah is associate director of the Hospital Medicine Unit at Brigham and Women’s Hospital.

References

1. Goldman L et al. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S-39S. doi: 10.1016/s0002-9343(01)00968-8.

2. Kripalani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007 Feb 28;297(8):831-41. doi: 10.1001/jama.297.8.831.

3. Scotten M et al. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Educ Couns. 2015 Jul;98(7):895-900. doi: 10.1016/j.pec.2015.03.009.

4. Back A et al. Communication skills in the age of COVID-19. Ann Intern Med. 2020 Jun 2;172(11):759-60. doi: 10.7326/M20-1376.

5. Hart JL et al. Family-centered care during the COVID-19 era. J Pain Symptom Manage. 2020 Aug;60(2):e93-7. doi: 10.1016/j.jpainsymman.2020.04.017.

6. Rubinelli S et al. Implications of the current COVID-19 pandemic for communication in healthcare. Patient Educ Couns. 2020 Jun;103(6):1067-9. doi: 10.1016/j.pec.2020.04.021.

7. Simpson N et al. Don’t forget shared decision-making in the COVID-19 crisis. Intern Med J. 2020 Jun;50(6):761-3. doi: 10.1111/imj.14862.
 

Case narrative

A 35-year-old woman has worsening alcoholic cirrhosis and repeated admissions for ascites, hepato-renal syndrome, and alcoholic hepatitis. Upon recognition of her grave prognosis, we proceeded with a shared-management approach involving medicine, gastroenterology, social work, chaplaincy, and palliative care. When the team spoke with the patient’s health care proxy (HCP), family, and friends for collateral information and involvement in goals of care conversation, we realized that none were aware of her months-long decline and poor prognosis for recovery to hospital discharge.

Haddad_Nichola_MA_web.jpg

Although several factors contributed to the disconnect between the patient and her support system, the obstacles were greatly exacerbated by profound changes in hospital protocol because of the COVID-19 pandemic. Physicians feel underprepared and challenged by prognostication and discussion of end of life during normal times; we believe COVID-19 has limited this essential physician role and led to tragic delays in effective communication and end of life planning.
 

Closing the loop

For patients with complex medical issues or those reaching end of life, effective communication within the health care system is critical. While inpatient teams often drive the plan, they care for their patients during a snapshot in time; contrarily, primary care providers and specialists often have established longitudinal relationships with their patients. Ergo, clinicians should communicate directly, and ideally with both patients and families, to achieve patient-centered and goal-concordant care.

Halporn_John_MA_web.jpg

For medically complex patients, PCPs tend to prefer verbal hand-offs. Timely and reliable communication between inpatient and outpatient providers has also been shown to prevent medical adverse events.¹ Despite this, direct communication occurs infrequently.² Given that hospitalists serve as primary inpatient providers for most general admissions, it is their responsibility to communicate with outpatient providers.

A multidisciplinary team redesigned the process by which PCPs were contacted following patient discharge. The transmission of information should ideally occur prior to discharge.³ Deficits in communication are extremely common and may negatively impact patient care, patient satisfaction, and patient safety.
 

Changes during the COVID-19 era

During the pandemic, patients have only one visitor per day, restricted visiting hours, and limited interactions with clinicians per implemented policies. Along with the increased burdens from personal protective equipment, remote hospital providers (social workers, case managers), and increased bureaucratic duties, COVID-19 has elucidated limitations in medical capacity and revealed the difficulties that clinicians face in communicating with patients and families, especially about serious illness.

Barkoudah_Ebrahim_MA_web.jpg

Tasks include facilitating virtual goodbyes between dying patients and families, conducting family meetings via teleconference, and discussing patient care with specialists through virtual technologies.⁴ While these tasks are arguably more important during a global disaster, COVID-19 paradoxically restricts physical presence and severely hinders communication.⁵ Clinicians should continue to utilize core skills like building rapport, assessing patient/family perspectives and agenda, and using empathy.⁶ Patients tend to more frequently value functional outcomes while clinicians tend to default to treatment modalities.⁷ Additionally, goals of care and end of life discussions are associated with improved quality of life, fewer aggressive medical interventions near death, and even increased survival.

Given the limited resources and difficulties in communication during the pandemic, clinicians should place greater emphasis on values-based shared decision-making. Internet-based solutions are essential and widely used, and videoconferencing has been initiated at the institutional scale at many hospitals. Many clinicians with little experience are broadly implementing these technologies.⁷ Despite these technological innovations, issues still arise in how to communicate effectively in the hospital setting, and we must acknowledge that strategies require devices, Internet access, and technological literacy, highlighting disparities in access to quality health care.⁶ Conversations during the pandemic will require listening, empathy, responsive action, and the acknowledgment of the social determinants of health.⁷

Improving communication and transition of care

Multiple steps will be warranted to implement the safe transition process and improve communication. High-quality patient care encompasses careful review of medications, communication between inpatient and outpatient providers, and close follow-up at discharge. These steps serve to increase our reliance on patient compliance and the exchange of information about global progression of disease.

The quantitative and qualitative steps of transition of care should overcome disconnect between teams, specifically deficit areas regarding postdischarge communication, monitoring, and understanding of prognosis around the relevance to this era of COVID-19.
 

Dr. Haddad is a resident physician in the psychiatry residency program at Brigham and Women’s Hospital, Boston. Dr. Halporn is clinic director, Division of Adult Palliative Care, in the department of psychosocial oncology and palliative care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Dr. Barkoudah is associate director of the Hospital Medicine Unit at Brigham and Women’s Hospital.

References

1. Goldman L et al. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S-39S. doi: 10.1016/s0002-9343(01)00968-8.

2. Kripalani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007 Feb 28;297(8):831-41. doi: 10.1001/jama.297.8.831.

3. Scotten M et al. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Educ Couns. 2015 Jul;98(7):895-900. doi: 10.1016/j.pec.2015.03.009.

4. Back A et al. Communication skills in the age of COVID-19. Ann Intern Med. 2020 Jun 2;172(11):759-60. doi: 10.7326/M20-1376.

5. Hart JL et al. Family-centered care during the COVID-19 era. J Pain Symptom Manage. 2020 Aug;60(2):e93-7. doi: 10.1016/j.jpainsymman.2020.04.017.

6. Rubinelli S et al. Implications of the current COVID-19 pandemic for communication in healthcare. Patient Educ Couns. 2020 Jun;103(6):1067-9. doi: 10.1016/j.pec.2020.04.021.

7. Simpson N et al. Don’t forget shared decision-making in the COVID-19 crisis. Intern Med J. 2020 Jun;50(6):761-3. doi: 10.1111/imj.14862.
 

Case narrative

A 35-year-old woman has worsening alcoholic cirrhosis and repeated admissions for ascites, hepato-renal syndrome, and alcoholic hepatitis. Upon recognition of her grave prognosis, we proceeded with a shared-management approach involving medicine, gastroenterology, social work, chaplaincy, and palliative care. When the team spoke with the patient’s health care proxy (HCP), family, and friends for collateral information and involvement in goals of care conversation, we realized that none were aware of her months-long decline and poor prognosis for recovery to hospital discharge.

Haddad_Nichola_MA_web.jpg

Although several factors contributed to the disconnect between the patient and her support system, the obstacles were greatly exacerbated by profound changes in hospital protocol because of the COVID-19 pandemic. Physicians feel underprepared and challenged by prognostication and discussion of end of life during normal times; we believe COVID-19 has limited this essential physician role and led to tragic delays in effective communication and end of life planning.
 

Closing the loop

For patients with complex medical issues or those reaching end of life, effective communication within the health care system is critical. While inpatient teams often drive the plan, they care for their patients during a snapshot in time; contrarily, primary care providers and specialists often have established longitudinal relationships with their patients. Ergo, clinicians should communicate directly, and ideally with both patients and families, to achieve patient-centered and goal-concordant care.

Halporn_John_MA_web.jpg

For medically complex patients, PCPs tend to prefer verbal hand-offs. Timely and reliable communication between inpatient and outpatient providers has also been shown to prevent medical adverse events.¹ Despite this, direct communication occurs infrequently.² Given that hospitalists serve as primary inpatient providers for most general admissions, it is their responsibility to communicate with outpatient providers.

A multidisciplinary team redesigned the process by which PCPs were contacted following patient discharge. The transmission of information should ideally occur prior to discharge.³ Deficits in communication are extremely common and may negatively impact patient care, patient satisfaction, and patient safety.
 

Changes during the COVID-19 era

During the pandemic, patients have only one visitor per day, restricted visiting hours, and limited interactions with clinicians per implemented policies. Along with the increased burdens from personal protective equipment, remote hospital providers (social workers, case managers), and increased bureaucratic duties, COVID-19 has elucidated limitations in medical capacity and revealed the difficulties that clinicians face in communicating with patients and families, especially about serious illness.

Barkoudah_Ebrahim_MA_web.jpg

Tasks include facilitating virtual goodbyes between dying patients and families, conducting family meetings via teleconference, and discussing patient care with specialists through virtual technologies.⁴ While these tasks are arguably more important during a global disaster, COVID-19 paradoxically restricts physical presence and severely hinders communication.⁵ Clinicians should continue to utilize core skills like building rapport, assessing patient/family perspectives and agenda, and using empathy.⁶ Patients tend to more frequently value functional outcomes while clinicians tend to default to treatment modalities.⁷ Additionally, goals of care and end of life discussions are associated with improved quality of life, fewer aggressive medical interventions near death, and even increased survival.

Given the limited resources and difficulties in communication during the pandemic, clinicians should place greater emphasis on values-based shared decision-making. Internet-based solutions are essential and widely used, and videoconferencing has been initiated at the institutional scale at many hospitals. Many clinicians with little experience are broadly implementing these technologies.⁷ Despite these technological innovations, issues still arise in how to communicate effectively in the hospital setting, and we must acknowledge that strategies require devices, Internet access, and technological literacy, highlighting disparities in access to quality health care.⁶ Conversations during the pandemic will require listening, empathy, responsive action, and the acknowledgment of the social determinants of health.⁷

Improving communication and transition of care

Multiple steps will be warranted to implement the safe transition process and improve communication. High-quality patient care encompasses careful review of medications, communication between inpatient and outpatient providers, and close follow-up at discharge. These steps serve to increase our reliance on patient compliance and the exchange of information about global progression of disease.

The quantitative and qualitative steps of transition of care should overcome disconnect between teams, specifically deficit areas regarding postdischarge communication, monitoring, and understanding of prognosis around the relevance to this era of COVID-19.
 

Dr. Haddad is a resident physician in the psychiatry residency program at Brigham and Women’s Hospital, Boston. Dr. Halporn is clinic director, Division of Adult Palliative Care, in the department of psychosocial oncology and palliative care, Dana-Farber Cancer Institute and Brigham and Women’s Hospital. Dr. Barkoudah is associate director of the Hospital Medicine Unit at Brigham and Women’s Hospital.

References

1. Goldman L et al. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S-39S. doi: 10.1016/s0002-9343(01)00968-8.

2. Kripalani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007 Feb 28;297(8):831-41. doi: 10.1001/jama.297.8.831.

3. Scotten M et al. Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient Educ Couns. 2015 Jul;98(7):895-900. doi: 10.1016/j.pec.2015.03.009.

4. Back A et al. Communication skills in the age of COVID-19. Ann Intern Med. 2020 Jun 2;172(11):759-60. doi: 10.7326/M20-1376.

5. Hart JL et al. Family-centered care during the COVID-19 era. J Pain Symptom Manage. 2020 Aug;60(2):e93-7. doi: 10.1016/j.jpainsymman.2020.04.017.

6. Rubinelli S et al. Implications of the current COVID-19 pandemic for communication in healthcare. Patient Educ Couns. 2020 Jun;103(6):1067-9. doi: 10.1016/j.pec.2020.04.021.

7. Simpson N et al. Don’t forget shared decision-making in the COVID-19 crisis. Intern Med J. 2020 Jun;50(6):761-3. doi: 10.1111/imj.14862.
 

Hospital and physician groups on Dec. 9 announced their plan to sue the federal government over its plan for addressing disputes about surprise medical bills, which tilts toward using prevailing rates paid for services.

The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.

Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.

Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.

The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.

In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.

AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.

In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”

The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.

“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”

AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”

“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.

AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.

“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.

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

Hospital and physician groups on Dec. 9 announced their plan to sue the federal government over its plan for addressing disputes about surprise medical bills, which tilts toward using prevailing rates paid for services.

The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.

Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.

Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.

The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.

In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.

AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.

In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”

The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.

“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”

AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”

“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.

AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.

“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.

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

Hospital and physician groups on Dec. 9 announced their plan to sue the federal government over its plan for addressing disputes about surprise medical bills, which tilts toward using prevailing rates paid for services.

The American Hospital Association and American Medical Association said they will ask the U.S. District Court for the District of Columbia to try to prevent implementation of certain provisions of new federal rules on surprise bills. This court is often a venue for fights over federal rules. Also joining the suit are Nevada-based Renown Health, UMass Memorial Health, and two physicians based in North Carolina, AHA and AMA said.

Federal agencies, including the Department of Health & Human Services, in September had unveiled the rule on surprise medical bills that will take effect Jan. 1.

Under this rule, a key benchmark for payment disputes would be the qualifying payment amount (QPA), which is pegged to median contracted rates. In the dispute-resolution process outlined in the rule, there is a presumption that the QPA is the appropriate out-of-network rate.

The rule allows for exceptions in which the independent mediating organization handling the payment dispute resolution has “credible information” as to why the QPA is materially different from the appropriate out-of-network rate.

In the view of the federal agencies that issued the rule, this approach “encourages predictable outcomes,” which likely would reduce the number of disputes that go through the resolution process while also “providing equitable and clear standards” for cases to appropriately deviate from QPA. HHS was joined in issuing the rule by the Treasury and Labor Departments and the Office of Personnel Management.

AMA and AHA disagree with their view, seeing this approach as a boon for insurers at the expense of physicians and hospitals.

In a press release, they said the rule’s approach to surprise billing would “all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers, and patients will have fewer choices for access to in-network services.”

The rule is part of the implementation of a federal law passed in December 2020, known as the No Surprises Act. In their statement, AHA and AMA said their legal challenge would not prevent “core patient protections’’ of that law from moving forward.

“No patient should fear receiving a surprise medical bill,” Rick Pollack, AHA president and chief executive, said in the statement. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”

AMA President Gerald E. Harmon, MD, added the approach used in the rule on surprise billing could create “an unsustainable situation for physicians.”

“Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies,” Dr. Harmon said.

AHA and AMA included with their statement a link to a November letter from more than 150 members of Congress, who also objected to the approach taken in designing the independent dispute-resolution (IDR) process.

“This directive establishes a de facto benchmark rate, making the median in-network rate the default factor considered in the IDR process. This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” wrote the members of Congress, including Rep. Raul Ruiz, MD, a California Democrat, and Rep. Larry Bucshon, MD, an Indiana Republican.

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

Background: Over 6 million Americans are prescribed anticoagulation; however, available anticoagulation options for patients with concomitant renal impairment are limited. Until recently, warfarin was the only recommended option because of a lack of data to support the use of alternative agents in such patients. This study evaluates the safety and effectiveness of apixaban, compared with warfarin, in patients with severe renal dysfunction.

Narayan_Amit_S_NY_web.jpg

The main limitation is the retrospective observational design, which may have introduced confounding variables that were not accounted for in the analyses. The study also did not account for patient nonadherence to medication.

Bottom line: Apixaban is a reasonable alternative to warfarin in patients with severe renal impairment.

Citation: Hanni C et al. Outcomes associated with apixaban vs. warfarin in patients with renal dysfunction. Blood Adv. 2020;4(11): 2366-71. doi: 10.1182/bloodadvances.2019000972.

Dr. Narayan is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: Over 6 million Americans are prescribed anticoagulation; however, available anticoagulation options for patients with concomitant renal impairment are limited. Until recently, warfarin was the only recommended option because of a lack of data to support the use of alternative agents in such patients. This study evaluates the safety and effectiveness of apixaban, compared with warfarin, in patients with severe renal dysfunction.

Narayan_Amit_S_NY_web.jpg

The main limitation is the retrospective observational design, which may have introduced confounding variables that were not accounted for in the analyses. The study also did not account for patient nonadherence to medication.

Bottom line: Apixaban is a reasonable alternative to warfarin in patients with severe renal impairment.

Citation: Hanni C et al. Outcomes associated with apixaban vs. warfarin in patients with renal dysfunction. Blood Adv. 2020;4(11): 2366-71. doi: 10.1182/bloodadvances.2019000972.

Dr. Narayan is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: Over 6 million Americans are prescribed anticoagulation; however, available anticoagulation options for patients with concomitant renal impairment are limited. Until recently, warfarin was the only recommended option because of a lack of data to support the use of alternative agents in such patients. This study evaluates the safety and effectiveness of apixaban, compared with warfarin, in patients with severe renal dysfunction.

Narayan_Amit_S_NY_web.jpg

The main limitation is the retrospective observational design, which may have introduced confounding variables that were not accounted for in the analyses. The study also did not account for patient nonadherence to medication.

Bottom line: Apixaban is a reasonable alternative to warfarin in patients with severe renal impairment.

Citation: Hanni C et al. Outcomes associated with apixaban vs. warfarin in patients with renal dysfunction. Blood Adv. 2020;4(11): 2366-71. doi: 10.1182/bloodadvances.2019000972.

Dr. Narayan is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Adolescents and adults younger than age 21 who develop myocarditis after mRNA COVID-19 vaccination frequently have abnormal findings on cardiac MRI (cMRI) but most have a mild clinical course with rapid resolution of symptoms, a new study concludes.

143796_Lloyd_Jones_Donald_web.jpg

• Most patients were male (90.6%), White (66.2%) and with a median age of 15.8 years.
• Suspected myocarditis occurred in 136 patients (97.8%) following mRNA vaccine, with 131 (94.2%) following the Pfizer-BioNTech vaccine; 128 cases (91.4%) occurred after the second dose.
• Symptoms started a median of 2 days (range 0 to 22 days) following vaccination administration.
• Chest pain was the most common symptom (99.3%), with fever present in 30.9% of patients and shortness of breath in 27.3%.
• Patients were treated with nonsteroidal anti-inflammatory drugs (81.3%), intravenous immunoglobulin (21.6%), glucocorticoids (21.6%), colchicine (7.9%) or no anti-inflammatory therapies (8.6%).
• Twenty-six patients (18.7%) were admitted to the intensive care unit; 2 received inotropic/vasoactive support; none required extracorporeal membrane oxygenation or died.
• Median time spent in the hospital was 2 days.
• A total of 111 patients had elevated troponin I (8.12 ng/mL) and 28 had elevated troponin T (0.61 ng/mL).
• More than two-thirds (69.8%) had abnormal electrocardiograms and/or arrhythmias (7 with nonsustained ventricular tachycardia).
• Twenty-six patients (18.7%) had left ventricular ejection fraction (LVEF) less than 55% on echocardiogram; LVEF had returned to normal in the 25 who returned for follow-up.
• 75 of 97 patients (77.3%) who underwent cMRI at a median of 5 days from symptom onset had abnormal findings; 74 (76.3%) had late gadolinium enhancement, 54 (55.7%) had myocardial edema, and 49 (50.5%) met Lake Louise criteria for myocarditis.

“These data suggest that most cases of suspected COVID-19 vaccine–related myocarditis in people younger than 21 are mild and resolve quickly,” corresponding author Dongngan Truong, MD, Division of Pediatric Cardiology, University of Utah and Primary Children’s Hospital, Salt Lake City, said in a statement.

“We were very happy to see that type of recovery. However, we are awaiting further studies to better understand the long-term outcomes of patients who have had COVID-19 vaccination-related myocarditis. We also need to study the risk factors and mechanisms for this rare complication,” Dr. Truong added.

Dr. Lloyd-Jones said these findings support the AHA’s position that COVID-19 vaccines are “safe, highly effective, and fundamental to saving lives, protecting our families and communities against COVID-19, and ending the pandemic.”

The study received no funding. Dr. Truong consults for Pfizer on vaccine-associated myocarditis. A complete list of author disclosures is available with the original article.

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

Adolescents and adults younger than age 21 who develop myocarditis after mRNA COVID-19 vaccination frequently have abnormal findings on cardiac MRI (cMRI) but most have a mild clinical course with rapid resolution of symptoms, a new study concludes.

143796_Lloyd_Jones_Donald_web.jpg

• Most patients were male (90.6%), White (66.2%) and with a median age of 15.8 years.
• Suspected myocarditis occurred in 136 patients (97.8%) following mRNA vaccine, with 131 (94.2%) following the Pfizer-BioNTech vaccine; 128 cases (91.4%) occurred after the second dose.
• Symptoms started a median of 2 days (range 0 to 22 days) following vaccination administration.
• Chest pain was the most common symptom (99.3%), with fever present in 30.9% of patients and shortness of breath in 27.3%.
• Patients were treated with nonsteroidal anti-inflammatory drugs (81.3%), intravenous immunoglobulin (21.6%), glucocorticoids (21.6%), colchicine (7.9%) or no anti-inflammatory therapies (8.6%).
• Twenty-six patients (18.7%) were admitted to the intensive care unit; 2 received inotropic/vasoactive support; none required extracorporeal membrane oxygenation or died.
• Median time spent in the hospital was 2 days.
• A total of 111 patients had elevated troponin I (8.12 ng/mL) and 28 had elevated troponin T (0.61 ng/mL).
• More than two-thirds (69.8%) had abnormal electrocardiograms and/or arrhythmias (7 with nonsustained ventricular tachycardia).
• Twenty-six patients (18.7%) had left ventricular ejection fraction (LVEF) less than 55% on echocardiogram; LVEF had returned to normal in the 25 who returned for follow-up.
• 75 of 97 patients (77.3%) who underwent cMRI at a median of 5 days from symptom onset had abnormal findings; 74 (76.3%) had late gadolinium enhancement, 54 (55.7%) had myocardial edema, and 49 (50.5%) met Lake Louise criteria for myocarditis.

“These data suggest that most cases of suspected COVID-19 vaccine–related myocarditis in people younger than 21 are mild and resolve quickly,” corresponding author Dongngan Truong, MD, Division of Pediatric Cardiology, University of Utah and Primary Children’s Hospital, Salt Lake City, said in a statement.

“We were very happy to see that type of recovery. However, we are awaiting further studies to better understand the long-term outcomes of patients who have had COVID-19 vaccination-related myocarditis. We also need to study the risk factors and mechanisms for this rare complication,” Dr. Truong added.

Dr. Lloyd-Jones said these findings support the AHA’s position that COVID-19 vaccines are “safe, highly effective, and fundamental to saving lives, protecting our families and communities against COVID-19, and ending the pandemic.”

The study received no funding. Dr. Truong consults for Pfizer on vaccine-associated myocarditis. A complete list of author disclosures is available with the original article.

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

Adolescents and adults younger than age 21 who develop myocarditis after mRNA COVID-19 vaccination frequently have abnormal findings on cardiac MRI (cMRI) but most have a mild clinical course with rapid resolution of symptoms, a new study concludes.

143796_Lloyd_Jones_Donald_web.jpg

• Most patients were male (90.6%), White (66.2%) and with a median age of 15.8 years.
• Suspected myocarditis occurred in 136 patients (97.8%) following mRNA vaccine, with 131 (94.2%) following the Pfizer-BioNTech vaccine; 128 cases (91.4%) occurred after the second dose.
• Symptoms started a median of 2 days (range 0 to 22 days) following vaccination administration.
• Chest pain was the most common symptom (99.3%), with fever present in 30.9% of patients and shortness of breath in 27.3%.
• Patients were treated with nonsteroidal anti-inflammatory drugs (81.3%), intravenous immunoglobulin (21.6%), glucocorticoids (21.6%), colchicine (7.9%) or no anti-inflammatory therapies (8.6%).
• Twenty-six patients (18.7%) were admitted to the intensive care unit; 2 received inotropic/vasoactive support; none required extracorporeal membrane oxygenation or died.
• Median time spent in the hospital was 2 days.
• A total of 111 patients had elevated troponin I (8.12 ng/mL) and 28 had elevated troponin T (0.61 ng/mL).
• More than two-thirds (69.8%) had abnormal electrocardiograms and/or arrhythmias (7 with nonsustained ventricular tachycardia).
• Twenty-six patients (18.7%) had left ventricular ejection fraction (LVEF) less than 55% on echocardiogram; LVEF had returned to normal in the 25 who returned for follow-up.
• 75 of 97 patients (77.3%) who underwent cMRI at a median of 5 days from symptom onset had abnormal findings; 74 (76.3%) had late gadolinium enhancement, 54 (55.7%) had myocardial edema, and 49 (50.5%) met Lake Louise criteria for myocarditis.

“These data suggest that most cases of suspected COVID-19 vaccine–related myocarditis in people younger than 21 are mild and resolve quickly,” corresponding author Dongngan Truong, MD, Division of Pediatric Cardiology, University of Utah and Primary Children’s Hospital, Salt Lake City, said in a statement.

“We were very happy to see that type of recovery. However, we are awaiting further studies to better understand the long-term outcomes of patients who have had COVID-19 vaccination-related myocarditis. We also need to study the risk factors and mechanisms for this rare complication,” Dr. Truong added.

Dr. Lloyd-Jones said these findings support the AHA’s position that COVID-19 vaccines are “safe, highly effective, and fundamental to saving lives, protecting our families and communities against COVID-19, and ending the pandemic.”

The study received no funding. Dr. Truong consults for Pfizer on vaccine-associated myocarditis. A complete list of author disclosures is available with the original article.

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

The year 2020 was unlike any in recent history, particularly for those working in health care. With the onset of the SARs-CoV-2 pandemic, many physicians were met with increasing clinical demands, and hospitalists served an instrumental role in providing medical care as the world faced an unprecedented need for health care resources.

Steed_Maura_web.jpg

In addition, 2020 was a year in which many of us reflected on inequities both inside and outside of medicine. Many in health care witnessed the disproportionate burden that the SARs-CoV-2 pandemic placed on communities of color and inequities pertaining to vaccine distribution.

Fisher_Rachel_MICH_web.jpg

In spite of the challenges of 2020, the field of pediatric hospital medicine (PHM) has continued to grow and evolve, with an incredible amount of new literature published in 2020.

Money_Nathan_UTAH_web.jpg

In this article, we identify the top 10 articles published in 2020, 5 of which are summarized below. These articles were presented at the Pediatric Update at SHM Converge 2021.
 

The top 5 articles

Association between parent comfort with English and adverse events among hospitalized children

Khan A et al. JAMA Pediatrics. December 2020.¹

Background: Hospitalized children experience similar rates of medical errors compared to adult patients, but higher rates in areas that could cause harm.¹ A major contributor to medical errors is communication failure, which language barriers frequently contribute to. Single-center data suggest that pediatric patients of families with limited comfort with English experience increased adverse events,² but multicenter data are lacking.

Findings: This prospective cohort study observed adverse event rates among 2,148 patients from seven teaching hospitals from December 2014 to January 2017. Survey data revealed 147 of 1,666 (9%) parents of patient families expressed limited comfort in English, and Spanish was the predominant language in this group (71%). There were 217 adverse events reported, 142 (65%) of which were deemed preventable by study personnel. Nearly twice as many children of parents with limited comfort with English experienced an adverse event when compared to their English-speaking counterparts (26 of 147 [17.7%] vs. 146 of 1,519 [9.6%]; adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Interpreter use was not measured.

Impact to practice: Children of parents with limited comfort with English are nearly twice as likely to experience adverse events when hospitalized. Hospitals should reflect on current practice and make efforts to improve their ability to identify and communicate with this vulnerable cohort.
 

Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children

Yeung F et al. Hospital Pediatrics. December 2020.³

Background: Peripheral intravenous catheter (PIV) insertion is performed on most hospitalized children. Unfortunately, PIVs frequently fail and need to be replaced. There is a widespread perception that infusing a crystalloid solution at a low rate through a PIV, a strategy known as “to keep vein open” (TKO) prolongs the patency of PIVs, however there is a lack of evidence to support this practice.⁴Findings: In this prospective, time-allocated study, 172 children were allocated to either a TKO strategy or a saline-lock strategy with a primary outcome of duration of PIV patency.³ Secondary outcomes included PIV–related complication rates and patient and caregiver satisfaction. The mean duration of PIV patency was 41.68 hours in the TKO group and 44.05 hours in the saline-lock group, which did not meet the prespecified definition of a clinically significant difference. There was no significant difference in prevalence of PIV-associated complications and patient satisfaction was similar between the two groups.

Impact to practice: Running fluid “to keep vein open” does not increase the duration of PIV patency compared to intermittent saline locks. Given that a TKO strategy limits a patient’s mobility, this low-value practice can be discontinued without increasing the risk of PIV failure.
 

Intensive care unit utilization after adoption of a ward-based high flow nasal cannula protocol

Coon ER et al. Journal of Hospital Medicine. June 2020.⁵

Background: High Flow Nasal Cannula (HFNC) has been widely adopted for escalation of respiratory support in patients with bronchiolitis; however, its use is dictated by highly variant local protocols.⁶ Small-scale randomized control trials and systematic reviews show that early HFNC initiation in mild to moderate disease does not change patient outcomes.⁷Findings: In this retrospective cohort study of ward-based HFNC, the authors used the Pediatric Health Information System database to identify 12 hospitals that had adopted ward-based HFNC protocols. The study used an interrupted time series analysis to compare outcomes for patients ages 3-24 months hospitalized with bronchiolitis (n = 32,809) in the three seasons before and after protocol adoption. Ward-based HFNC adoption paradoxically increased ICU admission (absolute increase 3.1%, 95% confidence interval, 2.8-3.4%) and ICU length of stay (absolute difference 9.1 days/100 patients, 95% CI, 5.1-13.2). Total length of stay and rates of mechanical ventilation were similar between groups.⁵Impact to practice: Ward-based HFNC protocols are associated with increased ICU utilization. As bronchiolitis is the leading diagnosis in pediatrics, pediatric hospitals can lead ward-based quality efforts to decrease HFNC overutilization focused on decreased initiation or deimplementation.
 

Lower versus traditional treatment threshold for neonatal hypoglycemia

Van Kempen AAMW et al. New England Journal of Medicine. February 2020.⁸

Background: Hypoglycemia is the most common metabolic abnormality in newborns, and up to 30% of newborns are routinely monitored for hypoglycemia. There is no consensus regarding the appropriate threshold at which hypoglycemia should be treated in order to prevent neurologic injury. Prior studies of neonatal hypoglycemia have largely been observation and have yielded conflicting results.⁸Findings: In this multicenter, randomized, noninferiority trial, 689 infants born at 35 weeks gestational age or later with risk factors for hypoglycemia and a measured blood glucose of 36-46 mg/dL were randomized to either a lower glucose treatment threshold (36 mg/dL) or traditional glucose treatment threshold (47 mg/dL). The primary outcome was psychomotor development at 18 months, assessed via the Bayley Scale of Infant and Toddler Development, third edition. There was no significant difference in cognitive or motor scores at 18 months. The lower treatment threshold group had a higher frequency of severe hypoglycemia (< 36 mg/dL) and were more likely to have four or more episodes of hypoglycemia. The traditional treatment threshold group had more supplemental feeding and more IV glucose administration. Length of stay for the mother and baby did not differ between groups.⁸

Impact to practice: This prospective, randomized study suggests that reducing the treatment threshold for neonatal hypoglycemia did not affect neurodevelopmental at 18 months of age. In contrast, a recent meta-analysis by Shah et al. suggested that neonatal hypoglycemia was not associated with adverse neurodevelopmental outcomes in early childhood; however, differences in rates of neurodevelopmental impairment, low literacy, and low numeracy were detectable by age five.⁹
 

Factors associated with family experience in pediatric inpatient care

Feng JY et al. Pediatrics. March 2020 Mar.¹⁰

Background: Positive patient experience is associated with better health care outcomes and reduced health care use.¹¹ Consequently, patient experience surveys have played a larger role in public reporting, financial risk sharing arrangements, and pay for performance programs. While adult studies have examined the importance of specific care dimensions for patient experience, data are lacking for inpatient pediatric populations.

Findings: A retrospective study collected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 17,727 patients in 69 hospitals within the United States over a 14-month period.¹⁰ Of the 10 care dimensions analyzed, child comfort (aOR 1.50; 95% CI, 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% CI, 1.42-1.58) were most strongly associated with a family’s willingness to recommend a hospital. Additional associated indices included preparing to leave the hospital (aOR 1.34; 95% CI, 1.27-1.41), doctor-parent communication (aOR 1.28; 95% CI, 1.21–1.35), and keeping parents informed (aOR 1.25; 95% CI, 1.18-1.33). Privacy and quietness, which are associated with positive patient experience in adult studies, were not significantly associated with willingness to recommend in this cohort.

Impact to practice: Hospitals seeking to improve patient experience will benefit most by focusing on improving patient comfort and nurse-parent communication. Factors that increase adult patient satisfaction may not be as important to the pediatric population and their families.



The other five articles that comprised the top 10 are listed below:
 

Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis

Coon ER et al. JAMA Pediatrics. September 2020.¹²

Clinical prediction rule for distinguishing bacterial from aseptic meningitis

Mintegi S et al. Pediatrics. September 2020.¹³

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC Ullman AJ et al. Pediatrics. June 2020.¹⁴

A structured neonatal parenting elective: An approach for parenting leave during residency

Cree-Green M et al. Academic Pediatrics. Aug 2020.¹⁵

The KidzMed project: Teaching children to swallow tablet medication

Tse Y et al. Archives of Disease in Childhood. November 2020.¹⁶

Dr. Steed is an internal medicine and pediatrics hospitalist at Northwestern Memorial Hospital and Ann and Robert H. Lurie’s Children’s Hospital of Chicago. Dr. Fisher is a current fellow in hospice and palliative medicine and a clinical assistant professor at Michigan State University. Dr. Money is an assistant professor of pediatrics at the University of Utah and a fellowship-trained pediatric hospitalist at Utah Valley Hospital and Primary Children’s Hospital.

References

1. Khan A et al. Association between parent comfort with english and adverse events among hospitalized children. JAMA Pediatr. 2020 Dec 1;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215.

2. Wasserman M et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. May-Jun 2014;36(3):5-16. doi: 10.1111/jhq.12065.

3. Yeung F et al. Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children. Hosp Pediatr. 2020 Dec;10(12):1038-43. doi: 10.1542/hpeds.2020-0137.

4. Mok E et al. A randomized controlled trial for maintaining peripheral intravenous lock in children. Int J Nurs Pract. 2007 Feb;13(1):33-45. doi: 10.1111/j.1440-172X.2006.00607.x.

5. Coon ER et al. Intensive care unit utilization after adoption of a ward-based high-flow nasal cannula protocol. J Hosp Med. 2020 Jun;15(6):325-30. doi: 10.12788/jhm.3417.

6. Kalburgi S and Halley T. High-flow nasal cannula use outside of the ICU setting. Pediatrics. 2020;146(5):e20194083. doi: 10.1542/peds.2019-4083.

7. Leyenaar JK and Ralston SL. Widespread adoption of low-value therapy: The case of bronchiolitis and high-flow oxygen. Pediatrics. 2020 Nov;146(5):e2020021188. doi: 10.1542/peds.2020-021188.

8. Van Kempen AAMW et al. Lower versus traditional treatment threshold for neonatal hypoglycemia. N Engl J Med. 2020 Feb 6;382(6):534-44. doi: 10.1056/NEJMoa1905593.

9. Shah R et al. Neonatal glycaemia and neurodevelopmental outcomes: A systematic review and meta-analysis. Neonatology. 2019;115(2):116-26. doi: 10.1159/000492859.

10. Feng JY et al. Factors associated with family experience in pediatric inpatient care. Pediatrics. 2020 Mar;145(3):e20191264. doi: 10.1542/peds.2019-1264.

11. Anhang Price R et al. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 2014 Oct;71(5):522-54. doi: 10.1177/1077558714541480.

12. Coon ER et al. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: The Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. 2020 Sep 1;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937.

13. Mintegi S et al. Clinical prediction rule for distinguishing bacterial from aseptic meningitis. Pediatrics. 2020 Sept;146(3): e20201126. doi: 10.1542/peds.2020-1126.

14. Ullman AJ et al. The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics: miniMAGIC. Pediatrics. 2020 Jun;145(Suppl 3):S269-S284. doi: 10.1542/peds.2019-3474I.

15. Cree-Green M et al. A structured neonatal parenting elective: an approach for parenting leave during residency. Acad Pediatr. 2021 Jan-Feb;21(1):16-18. doi: 10.1016/j.acap.2020.02.008.

16. Tse Y et al. The KidzMed project: Teaching children to swallow tablet medication. Arch Dis Child. 2020 Nov;105(11):1105-7. doi: 10.1136/archdischild-2019-317512.

The year 2020 was unlike any in recent history, particularly for those working in health care. With the onset of the SARs-CoV-2 pandemic, many physicians were met with increasing clinical demands, and hospitalists served an instrumental role in providing medical care as the world faced an unprecedented need for health care resources.

Steed_Maura_web.jpg

In addition, 2020 was a year in which many of us reflected on inequities both inside and outside of medicine. Many in health care witnessed the disproportionate burden that the SARs-CoV-2 pandemic placed on communities of color and inequities pertaining to vaccine distribution.

Fisher_Rachel_MICH_web.jpg

In spite of the challenges of 2020, the field of pediatric hospital medicine (PHM) has continued to grow and evolve, with an incredible amount of new literature published in 2020.

Money_Nathan_UTAH_web.jpg

In this article, we identify the top 10 articles published in 2020, 5 of which are summarized below. These articles were presented at the Pediatric Update at SHM Converge 2021.
 

The top 5 articles

Association between parent comfort with English and adverse events among hospitalized children

Khan A et al. JAMA Pediatrics. December 2020.¹

Background: Hospitalized children experience similar rates of medical errors compared to adult patients, but higher rates in areas that could cause harm.¹ A major contributor to medical errors is communication failure, which language barriers frequently contribute to. Single-center data suggest that pediatric patients of families with limited comfort with English experience increased adverse events,² but multicenter data are lacking.

Findings: This prospective cohort study observed adverse event rates among 2,148 patients from seven teaching hospitals from December 2014 to January 2017. Survey data revealed 147 of 1,666 (9%) parents of patient families expressed limited comfort in English, and Spanish was the predominant language in this group (71%). There were 217 adverse events reported, 142 (65%) of which were deemed preventable by study personnel. Nearly twice as many children of parents with limited comfort with English experienced an adverse event when compared to their English-speaking counterparts (26 of 147 [17.7%] vs. 146 of 1,519 [9.6%]; adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Interpreter use was not measured.

Impact to practice: Children of parents with limited comfort with English are nearly twice as likely to experience adverse events when hospitalized. Hospitals should reflect on current practice and make efforts to improve their ability to identify and communicate with this vulnerable cohort.
 

Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children

Yeung F et al. Hospital Pediatrics. December 2020.³

Background: Peripheral intravenous catheter (PIV) insertion is performed on most hospitalized children. Unfortunately, PIVs frequently fail and need to be replaced. There is a widespread perception that infusing a crystalloid solution at a low rate through a PIV, a strategy known as “to keep vein open” (TKO) prolongs the patency of PIVs, however there is a lack of evidence to support this practice.⁴Findings: In this prospective, time-allocated study, 172 children were allocated to either a TKO strategy or a saline-lock strategy with a primary outcome of duration of PIV patency.³ Secondary outcomes included PIV–related complication rates and patient and caregiver satisfaction. The mean duration of PIV patency was 41.68 hours in the TKO group and 44.05 hours in the saline-lock group, which did not meet the prespecified definition of a clinically significant difference. There was no significant difference in prevalence of PIV-associated complications and patient satisfaction was similar between the two groups.

Impact to practice: Running fluid “to keep vein open” does not increase the duration of PIV patency compared to intermittent saline locks. Given that a TKO strategy limits a patient’s mobility, this low-value practice can be discontinued without increasing the risk of PIV failure.
 

Intensive care unit utilization after adoption of a ward-based high flow nasal cannula protocol

Coon ER et al. Journal of Hospital Medicine. June 2020.⁵

Background: High Flow Nasal Cannula (HFNC) has been widely adopted for escalation of respiratory support in patients with bronchiolitis; however, its use is dictated by highly variant local protocols.⁶ Small-scale randomized control trials and systematic reviews show that early HFNC initiation in mild to moderate disease does not change patient outcomes.⁷Findings: In this retrospective cohort study of ward-based HFNC, the authors used the Pediatric Health Information System database to identify 12 hospitals that had adopted ward-based HFNC protocols. The study used an interrupted time series analysis to compare outcomes for patients ages 3-24 months hospitalized with bronchiolitis (n = 32,809) in the three seasons before and after protocol adoption. Ward-based HFNC adoption paradoxically increased ICU admission (absolute increase 3.1%, 95% confidence interval, 2.8-3.4%) and ICU length of stay (absolute difference 9.1 days/100 patients, 95% CI, 5.1-13.2). Total length of stay and rates of mechanical ventilation were similar between groups.⁵Impact to practice: Ward-based HFNC protocols are associated with increased ICU utilization. As bronchiolitis is the leading diagnosis in pediatrics, pediatric hospitals can lead ward-based quality efforts to decrease HFNC overutilization focused on decreased initiation or deimplementation.
 

Lower versus traditional treatment threshold for neonatal hypoglycemia

Van Kempen AAMW et al. New England Journal of Medicine. February 2020.⁸

Background: Hypoglycemia is the most common metabolic abnormality in newborns, and up to 30% of newborns are routinely monitored for hypoglycemia. There is no consensus regarding the appropriate threshold at which hypoglycemia should be treated in order to prevent neurologic injury. Prior studies of neonatal hypoglycemia have largely been observation and have yielded conflicting results.⁸Findings: In this multicenter, randomized, noninferiority trial, 689 infants born at 35 weeks gestational age or later with risk factors for hypoglycemia and a measured blood glucose of 36-46 mg/dL were randomized to either a lower glucose treatment threshold (36 mg/dL) or traditional glucose treatment threshold (47 mg/dL). The primary outcome was psychomotor development at 18 months, assessed via the Bayley Scale of Infant and Toddler Development, third edition. There was no significant difference in cognitive or motor scores at 18 months. The lower treatment threshold group had a higher frequency of severe hypoglycemia (< 36 mg/dL) and were more likely to have four or more episodes of hypoglycemia. The traditional treatment threshold group had more supplemental feeding and more IV glucose administration. Length of stay for the mother and baby did not differ between groups.⁸

Impact to practice: This prospective, randomized study suggests that reducing the treatment threshold for neonatal hypoglycemia did not affect neurodevelopmental at 18 months of age. In contrast, a recent meta-analysis by Shah et al. suggested that neonatal hypoglycemia was not associated with adverse neurodevelopmental outcomes in early childhood; however, differences in rates of neurodevelopmental impairment, low literacy, and low numeracy were detectable by age five.⁹
 

Factors associated with family experience in pediatric inpatient care

Feng JY et al. Pediatrics. March 2020 Mar.¹⁰

Background: Positive patient experience is associated with better health care outcomes and reduced health care use.¹¹ Consequently, patient experience surveys have played a larger role in public reporting, financial risk sharing arrangements, and pay for performance programs. While adult studies have examined the importance of specific care dimensions for patient experience, data are lacking for inpatient pediatric populations.

Findings: A retrospective study collected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 17,727 patients in 69 hospitals within the United States over a 14-month period.¹⁰ Of the 10 care dimensions analyzed, child comfort (aOR 1.50; 95% CI, 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% CI, 1.42-1.58) were most strongly associated with a family’s willingness to recommend a hospital. Additional associated indices included preparing to leave the hospital (aOR 1.34; 95% CI, 1.27-1.41), doctor-parent communication (aOR 1.28; 95% CI, 1.21–1.35), and keeping parents informed (aOR 1.25; 95% CI, 1.18-1.33). Privacy and quietness, which are associated with positive patient experience in adult studies, were not significantly associated with willingness to recommend in this cohort.

Impact to practice: Hospitals seeking to improve patient experience will benefit most by focusing on improving patient comfort and nurse-parent communication. Factors that increase adult patient satisfaction may not be as important to the pediatric population and their families.



The other five articles that comprised the top 10 are listed below:
 

Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis

Coon ER et al. JAMA Pediatrics. September 2020.¹²

Clinical prediction rule for distinguishing bacterial from aseptic meningitis

Mintegi S et al. Pediatrics. September 2020.¹³

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC Ullman AJ et al. Pediatrics. June 2020.¹⁴

A structured neonatal parenting elective: An approach for parenting leave during residency

Cree-Green M et al. Academic Pediatrics. Aug 2020.¹⁵

The KidzMed project: Teaching children to swallow tablet medication

Tse Y et al. Archives of Disease in Childhood. November 2020.¹⁶

Dr. Steed is an internal medicine and pediatrics hospitalist at Northwestern Memorial Hospital and Ann and Robert H. Lurie’s Children’s Hospital of Chicago. Dr. Fisher is a current fellow in hospice and palliative medicine and a clinical assistant professor at Michigan State University. Dr. Money is an assistant professor of pediatrics at the University of Utah and a fellowship-trained pediatric hospitalist at Utah Valley Hospital and Primary Children’s Hospital.

References

1. Khan A et al. Association between parent comfort with english and adverse events among hospitalized children. JAMA Pediatr. 2020 Dec 1;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215.

2. Wasserman M et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. May-Jun 2014;36(3):5-16. doi: 10.1111/jhq.12065.

3. Yeung F et al. Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children. Hosp Pediatr. 2020 Dec;10(12):1038-43. doi: 10.1542/hpeds.2020-0137.

4. Mok E et al. A randomized controlled trial for maintaining peripheral intravenous lock in children. Int J Nurs Pract. 2007 Feb;13(1):33-45. doi: 10.1111/j.1440-172X.2006.00607.x.

5. Coon ER et al. Intensive care unit utilization after adoption of a ward-based high-flow nasal cannula protocol. J Hosp Med. 2020 Jun;15(6):325-30. doi: 10.12788/jhm.3417.

6. Kalburgi S and Halley T. High-flow nasal cannula use outside of the ICU setting. Pediatrics. 2020;146(5):e20194083. doi: 10.1542/peds.2019-4083.

7. Leyenaar JK and Ralston SL. Widespread adoption of low-value therapy: The case of bronchiolitis and high-flow oxygen. Pediatrics. 2020 Nov;146(5):e2020021188. doi: 10.1542/peds.2020-021188.

8. Van Kempen AAMW et al. Lower versus traditional treatment threshold for neonatal hypoglycemia. N Engl J Med. 2020 Feb 6;382(6):534-44. doi: 10.1056/NEJMoa1905593.

9. Shah R et al. Neonatal glycaemia and neurodevelopmental outcomes: A systematic review and meta-analysis. Neonatology. 2019;115(2):116-26. doi: 10.1159/000492859.

10. Feng JY et al. Factors associated with family experience in pediatric inpatient care. Pediatrics. 2020 Mar;145(3):e20191264. doi: 10.1542/peds.2019-1264.

11. Anhang Price R et al. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 2014 Oct;71(5):522-54. doi: 10.1177/1077558714541480.

12. Coon ER et al. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: The Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. 2020 Sep 1;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937.

13. Mintegi S et al. Clinical prediction rule for distinguishing bacterial from aseptic meningitis. Pediatrics. 2020 Sept;146(3): e20201126. doi: 10.1542/peds.2020-1126.

14. Ullman AJ et al. The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics: miniMAGIC. Pediatrics. 2020 Jun;145(Suppl 3):S269-S284. doi: 10.1542/peds.2019-3474I.

15. Cree-Green M et al. A structured neonatal parenting elective: an approach for parenting leave during residency. Acad Pediatr. 2021 Jan-Feb;21(1):16-18. doi: 10.1016/j.acap.2020.02.008.

16. Tse Y et al. The KidzMed project: Teaching children to swallow tablet medication. Arch Dis Child. 2020 Nov;105(11):1105-7. doi: 10.1136/archdischild-2019-317512.

The year 2020 was unlike any in recent history, particularly for those working in health care. With the onset of the SARs-CoV-2 pandemic, many physicians were met with increasing clinical demands, and hospitalists served an instrumental role in providing medical care as the world faced an unprecedented need for health care resources.

Steed_Maura_web.jpg

In addition, 2020 was a year in which many of us reflected on inequities both inside and outside of medicine. Many in health care witnessed the disproportionate burden that the SARs-CoV-2 pandemic placed on communities of color and inequities pertaining to vaccine distribution.

Fisher_Rachel_MICH_web.jpg

In spite of the challenges of 2020, the field of pediatric hospital medicine (PHM) has continued to grow and evolve, with an incredible amount of new literature published in 2020.

Money_Nathan_UTAH_web.jpg

In this article, we identify the top 10 articles published in 2020, 5 of which are summarized below. These articles were presented at the Pediatric Update at SHM Converge 2021.
 

The top 5 articles

Association between parent comfort with English and adverse events among hospitalized children

Khan A et al. JAMA Pediatrics. December 2020.¹

Background: Hospitalized children experience similar rates of medical errors compared to adult patients, but higher rates in areas that could cause harm.¹ A major contributor to medical errors is communication failure, which language barriers frequently contribute to. Single-center data suggest that pediatric patients of families with limited comfort with English experience increased adverse events,² but multicenter data are lacking.

Findings: This prospective cohort study observed adverse event rates among 2,148 patients from seven teaching hospitals from December 2014 to January 2017. Survey data revealed 147 of 1,666 (9%) parents of patient families expressed limited comfort in English, and Spanish was the predominant language in this group (71%). There were 217 adverse events reported, 142 (65%) of which were deemed preventable by study personnel. Nearly twice as many children of parents with limited comfort with English experienced an adverse event when compared to their English-speaking counterparts (26 of 147 [17.7%] vs. 146 of 1,519 [9.6%]; adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Interpreter use was not measured.

Impact to practice: Children of parents with limited comfort with English are nearly twice as likely to experience adverse events when hospitalized. Hospitals should reflect on current practice and make efforts to improve their ability to identify and communicate with this vulnerable cohort.
 

Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children

Yeung F et al. Hospital Pediatrics. December 2020.³

Background: Peripheral intravenous catheter (PIV) insertion is performed on most hospitalized children. Unfortunately, PIVs frequently fail and need to be replaced. There is a widespread perception that infusing a crystalloid solution at a low rate through a PIV, a strategy known as “to keep vein open” (TKO) prolongs the patency of PIVs, however there is a lack of evidence to support this practice.⁴Findings: In this prospective, time-allocated study, 172 children were allocated to either a TKO strategy or a saline-lock strategy with a primary outcome of duration of PIV patency.³ Secondary outcomes included PIV–related complication rates and patient and caregiver satisfaction. The mean duration of PIV patency was 41.68 hours in the TKO group and 44.05 hours in the saline-lock group, which did not meet the prespecified definition of a clinically significant difference. There was no significant difference in prevalence of PIV-associated complications and patient satisfaction was similar between the two groups.

Impact to practice: Running fluid “to keep vein open” does not increase the duration of PIV patency compared to intermittent saline locks. Given that a TKO strategy limits a patient’s mobility, this low-value practice can be discontinued without increasing the risk of PIV failure.
 

Intensive care unit utilization after adoption of a ward-based high flow nasal cannula protocol

Coon ER et al. Journal of Hospital Medicine. June 2020.⁵

Background: High Flow Nasal Cannula (HFNC) has been widely adopted for escalation of respiratory support in patients with bronchiolitis; however, its use is dictated by highly variant local protocols.⁶ Small-scale randomized control trials and systematic reviews show that early HFNC initiation in mild to moderate disease does not change patient outcomes.⁷Findings: In this retrospective cohort study of ward-based HFNC, the authors used the Pediatric Health Information System database to identify 12 hospitals that had adopted ward-based HFNC protocols. The study used an interrupted time series analysis to compare outcomes for patients ages 3-24 months hospitalized with bronchiolitis (n = 32,809) in the three seasons before and after protocol adoption. Ward-based HFNC adoption paradoxically increased ICU admission (absolute increase 3.1%, 95% confidence interval, 2.8-3.4%) and ICU length of stay (absolute difference 9.1 days/100 patients, 95% CI, 5.1-13.2). Total length of stay and rates of mechanical ventilation were similar between groups.⁵Impact to practice: Ward-based HFNC protocols are associated with increased ICU utilization. As bronchiolitis is the leading diagnosis in pediatrics, pediatric hospitals can lead ward-based quality efforts to decrease HFNC overutilization focused on decreased initiation or deimplementation.
 

Lower versus traditional treatment threshold for neonatal hypoglycemia

Van Kempen AAMW et al. New England Journal of Medicine. February 2020.⁸

Background: Hypoglycemia is the most common metabolic abnormality in newborns, and up to 30% of newborns are routinely monitored for hypoglycemia. There is no consensus regarding the appropriate threshold at which hypoglycemia should be treated in order to prevent neurologic injury. Prior studies of neonatal hypoglycemia have largely been observation and have yielded conflicting results.⁸Findings: In this multicenter, randomized, noninferiority trial, 689 infants born at 35 weeks gestational age or later with risk factors for hypoglycemia and a measured blood glucose of 36-46 mg/dL were randomized to either a lower glucose treatment threshold (36 mg/dL) or traditional glucose treatment threshold (47 mg/dL). The primary outcome was psychomotor development at 18 months, assessed via the Bayley Scale of Infant and Toddler Development, third edition. There was no significant difference in cognitive or motor scores at 18 months. The lower treatment threshold group had a higher frequency of severe hypoglycemia (< 36 mg/dL) and were more likely to have four or more episodes of hypoglycemia. The traditional treatment threshold group had more supplemental feeding and more IV glucose administration. Length of stay for the mother and baby did not differ between groups.⁸

Impact to practice: This prospective, randomized study suggests that reducing the treatment threshold for neonatal hypoglycemia did not affect neurodevelopmental at 18 months of age. In contrast, a recent meta-analysis by Shah et al. suggested that neonatal hypoglycemia was not associated with adverse neurodevelopmental outcomes in early childhood; however, differences in rates of neurodevelopmental impairment, low literacy, and low numeracy were detectable by age five.⁹
 

Factors associated with family experience in pediatric inpatient care

Feng JY et al. Pediatrics. March 2020 Mar.¹⁰

Background: Positive patient experience is associated with better health care outcomes and reduced health care use.¹¹ Consequently, patient experience surveys have played a larger role in public reporting, financial risk sharing arrangements, and pay for performance programs. While adult studies have examined the importance of specific care dimensions for patient experience, data are lacking for inpatient pediatric populations.

Findings: A retrospective study collected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 17,727 patients in 69 hospitals within the United States over a 14-month period.¹⁰ Of the 10 care dimensions analyzed, child comfort (aOR 1.50; 95% CI, 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% CI, 1.42-1.58) were most strongly associated with a family’s willingness to recommend a hospital. Additional associated indices included preparing to leave the hospital (aOR 1.34; 95% CI, 1.27-1.41), doctor-parent communication (aOR 1.28; 95% CI, 1.21–1.35), and keeping parents informed (aOR 1.25; 95% CI, 1.18-1.33). Privacy and quietness, which are associated with positive patient experience in adult studies, were not significantly associated with willingness to recommend in this cohort.

Impact to practice: Hospitals seeking to improve patient experience will benefit most by focusing on improving patient comfort and nurse-parent communication. Factors that increase adult patient satisfaction may not be as important to the pediatric population and their families.



The other five articles that comprised the top 10 are listed below:
 

Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis

Coon ER et al. JAMA Pediatrics. September 2020.¹²

Clinical prediction rule for distinguishing bacterial from aseptic meningitis

Mintegi S et al. Pediatrics. September 2020.¹³

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC Ullman AJ et al. Pediatrics. June 2020.¹⁴

A structured neonatal parenting elective: An approach for parenting leave during residency

Cree-Green M et al. Academic Pediatrics. Aug 2020.¹⁵

The KidzMed project: Teaching children to swallow tablet medication

Tse Y et al. Archives of Disease in Childhood. November 2020.¹⁶

Dr. Steed is an internal medicine and pediatrics hospitalist at Northwestern Memorial Hospital and Ann and Robert H. Lurie’s Children’s Hospital of Chicago. Dr. Fisher is a current fellow in hospice and palliative medicine and a clinical assistant professor at Michigan State University. Dr. Money is an assistant professor of pediatrics at the University of Utah and a fellowship-trained pediatric hospitalist at Utah Valley Hospital and Primary Children’s Hospital.

References

1. Khan A et al. Association between parent comfort with english and adverse events among hospitalized children. JAMA Pediatr. 2020 Dec 1;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215.

2. Wasserman M et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. May-Jun 2014;36(3):5-16. doi: 10.1111/jhq.12065.

3. Yeung F et al. Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children. Hosp Pediatr. 2020 Dec;10(12):1038-43. doi: 10.1542/hpeds.2020-0137.

4. Mok E et al. A randomized controlled trial for maintaining peripheral intravenous lock in children. Int J Nurs Pract. 2007 Feb;13(1):33-45. doi: 10.1111/j.1440-172X.2006.00607.x.

5. Coon ER et al. Intensive care unit utilization after adoption of a ward-based high-flow nasal cannula protocol. J Hosp Med. 2020 Jun;15(6):325-30. doi: 10.12788/jhm.3417.

6. Kalburgi S and Halley T. High-flow nasal cannula use outside of the ICU setting. Pediatrics. 2020;146(5):e20194083. doi: 10.1542/peds.2019-4083.

7. Leyenaar JK and Ralston SL. Widespread adoption of low-value therapy: The case of bronchiolitis and high-flow oxygen. Pediatrics. 2020 Nov;146(5):e2020021188. doi: 10.1542/peds.2020-021188.

8. Van Kempen AAMW et al. Lower versus traditional treatment threshold for neonatal hypoglycemia. N Engl J Med. 2020 Feb 6;382(6):534-44. doi: 10.1056/NEJMoa1905593.

9. Shah R et al. Neonatal glycaemia and neurodevelopmental outcomes: A systematic review and meta-analysis. Neonatology. 2019;115(2):116-26. doi: 10.1159/000492859.

10. Feng JY et al. Factors associated with family experience in pediatric inpatient care. Pediatrics. 2020 Mar;145(3):e20191264. doi: 10.1542/peds.2019-1264.

11. Anhang Price R et al. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 2014 Oct;71(5):522-54. doi: 10.1177/1077558714541480.

12. Coon ER et al. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: The Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. 2020 Sep 1;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937.

13. Mintegi S et al. Clinical prediction rule for distinguishing bacterial from aseptic meningitis. Pediatrics. 2020 Sept;146(3): e20201126. doi: 10.1542/peds.2020-1126.

14. Ullman AJ et al. The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics: miniMAGIC. Pediatrics. 2020 Jun;145(Suppl 3):S269-S284. doi: 10.1542/peds.2019-3474I.

15. Cree-Green M et al. A structured neonatal parenting elective: an approach for parenting leave during residency. Acad Pediatr. 2021 Jan-Feb;21(1):16-18. doi: 10.1016/j.acap.2020.02.008.

16. Tse Y et al. The KidzMed project: Teaching children to swallow tablet medication. Arch Dis Child. 2020 Nov;105(11):1105-7. doi: 10.1136/archdischild-2019-317512.

Background: Acute kidney injury (AKI) is a common complication that occurs in seriously ill patients admitted to the ICU, and many of these patients eventually require RRT. When complicated by major metabolic disorders, it is usually clear when therapy should be initiated. However, when these complications are absent, the most appropriate time to initiate RRT is unclear. There are potential advantages to performing early RRT in patients with severe AKI, such as restoring acid-base balance, preventing fluid accumulation, and preventing major electrolyte disturbances.

Kim_Andrew_NY_web.jpg

Dr. Kim is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: Acute kidney injury (AKI) is a common complication that occurs in seriously ill patients admitted to the ICU, and many of these patients eventually require RRT. When complicated by major metabolic disorders, it is usually clear when therapy should be initiated. However, when these complications are absent, the most appropriate time to initiate RRT is unclear. There are potential advantages to performing early RRT in patients with severe AKI, such as restoring acid-base balance, preventing fluid accumulation, and preventing major electrolyte disturbances.

Kim_Andrew_NY_web.jpg

Dr. Kim is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: Acute kidney injury (AKI) is a common complication that occurs in seriously ill patients admitted to the ICU, and many of these patients eventually require RRT. When complicated by major metabolic disorders, it is usually clear when therapy should be initiated. However, when these complications are absent, the most appropriate time to initiate RRT is unclear. There are potential advantages to performing early RRT in patients with severe AKI, such as restoring acid-base balance, preventing fluid accumulation, and preventing major electrolyte disturbances.

Kim_Andrew_NY_web.jpg

Dr. Kim is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

In 2011, the Mayo Clinic began surveying physicians about burnout and found 45% of physicians experienced at least one symptom, such as emotional exhaustion, finding work no longer meaningful, feelings of ineffectiveness, and depersonalizing patients. Associated manifestations can range from headache and insomnia to impaired memory and decreased attention. 

meditation_1039533792_web2.jpg

Fast forward 10 years to the Medscape National Physician Burnout and Suicide Report, which found that a similar number of physicians (42%) feel burned out. The COVID-19 pandemic only added insult to injury. A Medscape survey that included nearly 5,000 U.S. physicians revealed that about two-thirds (64%) of them reported burnout had intensified during the crisis.

These elevated numbers are being labeled as “a public health crisis” for the impact widespread physician burnout could have on the health of the doctor and patient safety. The relatively consistent levels across the decade seem to suggest that, if health organizations are attempting to improve physician well-being, it doesn’t appear to be working, forcing doctors to find solutions for themselves.

Jill Wener, MD, considers herself part of the 45% burned out 10 years ago. She was working as an internist at Rush University Medical Center in Chicago, but the “existential reality of being a doctor in this world” was wearing on her. “Staying up with the literature, knowing that every day you’re going to go into work without knowing what you’re going to find, threats of lawsuits, the pressure of perfectionism,” Dr. Wener told this news organization. “By the time I hit burnout, everything made me feel like the world was crashing down on me.”

When Dr. Wener encountered someone who meditated twice a day, she was intrigued, even though the self-described “most Type-A, inside-the-box, nonspiritual type, anxious, linear-path doctor” didn’t think people like her could meditate. Dr. Wener is not alone in her hesitation to explore meditation as a means to help prevent burnout because the causes of burnout are primarily linked to external rather than internal factors. Issues including a loss of autonomy, the burden and distraction of electronic health records, and the intense pressure to comply with rules from the government are not things mindfulness can fix. 

Wener_Jill_GA_web2.jpg

And because the sources of burnout are primarily environmental and inherent to the current medical system, the suggestion that physicians need to fix themselves with meditation can come as a slap in the face. However, when up against a system slow to change, mindfulness can provide physicians access to the one thing they can control: How they perceive and react to what’s in front of them.

At the recommendation of an acquaintance, Dr. Wener enrolled in a Vedic Meditation (also known as Conscious Health Meditation) course taught by Light Watkins, a well-known traveling instructor, author, and speaker. By the second meeting she was successfully practicing 20 minutes twice a day. This form of mediation traces its roots to the Vedas, ancient Indian texts (also the foundation for yoga), and uses a mantra to settle the mind, transitioning to an awake state of inner contentment. 

Three weeks later, Dr. Wener’s daily crying jags ended as did her propensity for road rage. “I felt like I was on the cusp of something life-changing, I just didn’t understand it,” she recalled. “But I knew I was never going to give it up.”
 

Defining mindfulness

“Mindfulness is being able to be present in the moment that you’re in with acceptance of what it is and without judging it,” said Donna Rockwell, PsyD, a leading mindfulness meditation teacher. The practice of mindfulness is really meditation. Dr. Rockwell explained that the noise of our mind is most often focused on either the past or the future. “We’re either bemoaning something that happened earlier or we’re catastrophizing the future,” she said, which prevents us from being present in the moment. 

Meditation allows you to notice when your mind has drifted from the present moment into the past or future. “You gently notice it, label it with a lot of self-compassion, and then bring your mind back by focusing on your breath – going out, going in – and the incoming stimuli through your five senses,” said Dr. Rockwell. “When you’re doing that, you can’t be in the past or future.”

Dr. Rockwell also pointed out that we constantly categorize incoming data of the moment as either “good for me or bad for me,” which gets in the way of simply being present for what you’re facing. “When you’re more fully present, you become more skillful and able to do what this moment is asking of you,” she said. Being mindful allows us to better navigate incoming stimuli, which could be a “code blue” in the ED or a patient who needs another 2 minutes during an office visit. 

When Dr. Wener was burned out, she felt unable to adapt whenever something unexpected happened. “When you have no emotional reserves, everything feels like a big deal,” she said. “The meditation gave me what we call adaptation energy; it filled up my tank and kept me from feeling like I was going to lose it at 10 o’clock in the morning.”

Dr. Rockwell explained burnout as an overactive fight or flight response activated by the amygdala. It starts pumping cortisol, our pupils dilate, and our pores open. The prefrontal cortex is offline when we’re experiencing this physiological response because they both can’t be operational at the same time. “When we’re constantly in a ‘fight or flight’ response and don’t have any access to our prefrontal cortex, we are coming from a brain that is pumping cortisol and that leads to burnout,” said Dr. Rockwell.

“Any fight or flight response leaves a mark on your body,” Dr. Wener echoed. “When we go into our state of deep rest in the meditation practice, which is two to five times more restful than sleep, it heals those stress scars.”
 

Making time for mindfulness

Prescribing mindfulness for physicians is not new. Molecular biologist Jon Kabat-Zinn, PhD, developed Mindfulness-Based Stress Reduction (MBSR) in 1979, a practice that incorporates mindfulness exercises to help people become familiar with their behavior patterns in stressful situations. Thus, instead of reacting, they can respond with a clearer understanding of the circumstance. Dr. Kabat-Zinn initially targeted people with chronic health problems to help them cope with the effects of pain and the condition of their illness, but it has expanded to anyone experiencing challenges in their life, including physicians. A standard MBSR course runs 8 weeks, making it a commitment for most people. 

Mindfulness training requires that physicians use what they already have so little of: time.

Dr. Wener was able to take a sabbatical, embarking on a 3-month trip to India to immerse herself in the study of Vedic Meditation. Upon her return, Dr. Wener took a position at Emory University, Atlanta, and has launched a number of CME-accredited meditation courses and retreats. Unlike Dr. Kabat-Zinn, her programs are by physicians and for physicians. She also created an online version of the meditation course to make it more accessible. 

For these reasons, Kara Pepper, MD, an internist in outpatient primary care in Atlanta, was drawn to the meditation course. Dr. Pepper was 7 years into practice when she burned out. “The program dovetailed into my burnout recovery,” she said. “It allowed me space to separate myself from the thoughts I was having about work and just recognize them as just that – as thoughts.”

In the course, Dr. Wener teaches the REST Technique, which she says is different than mindfulness in that she encourages the mind to run rampant. “Trying to control the mind can feel very uncomfortable because we always have thoughts,” she says. “We can’t tell the mind to stop thinking just like we can’t tell the heart to stop beating.” Dr. Wener said the REST Technique lets “the mind swim downstream,” allowing the brain to go into a deep state of rest and start to heal from the scars caused by stress. 

Dr. Pepper said the self-paced online course gave her all the tools she needed, and it was pragmatic and evidence based. “I didn’t feel ‘woo’ or like another gimmick,” she said. Pepper, who continues to practice medicine, became a life coach in 2019 to teach others the skills she uses daily. 
 

An integrated strategy

Dr. Wener acknowledges that meditation is not the panacea for everyone’s burnout, which data support. In a review published in The American Journal of Medicine in 2019, Scott Yates, MD, MBA, from the Center for Executive Medicine in Plano, Tex., found that physicians who had adopted mediation and mindfulness training to decrease anxiety and perceived work stress only experienced modest benefits. In fact, Dr. Yates claims that there’s little data to suggest the long-term benefit of any particular stress management intervention in the prevention of burnout symptoms. 

“The often-repeated goals of the Triple Aim [enhancing patient experience, improving population health, and reducing costs] may be unreachable until we recognize and address burnout in health care providers,” Dr. Yates wrote. He recommends adding a fourth goal to specifically address physician wellness, which certainly could include mindfulness training and meditation.

Burnout coach, trainer, and consultant Dike Drummond, MD, also professes that physician wellness must be added as the key fourth ingredient to improving health care. “Burnout is a dilemma, a balancing act,” he said. “It takes an integrated strategy.” The CEO and founder of TheHappyMD.com, Dr. Drummond’s integrated strategy to stop physician burnout has been taught to more than 40,000 physicians in 175 organizations, and one element of that strategy can be mindfulness training. 

Dr. Drummond said he doesn’t use the word meditation “because that scares most people”; it takes a commitment and isn’t accessible for a lot of doctors. Instead, he coaches doctors to use a ‘single-breath’ technique to help them reset multiple times throughout the day. “I teach people how to breathe up to the top of their head and then down to the bottom of their feet,” Dr. Drummond said. He calls it the Squeegee Breath Technique because when they exhale, they “wipe away” anything that doesn’t need to be there right now. “If you happen to have a mindfulness practice like meditation, they work synergistically because the calmness you feel in your mediation is available to you at the bottom of these releasing breaths.”

Various studies and surveys provide great detail as to the “why” of physician burnout. And while mindfulness is not the sole answer, it’s something physicians can explore for themselves while health care as an industry looks for a more comprehensive solution. 

“It’s not rocket science,” Dr. Drummond insisted. “You want a different result? You’re not satisfied with the way things are now and you want to feel different? You absolutely must do something different.”

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

In 2011, the Mayo Clinic began surveying physicians about burnout and found 45% of physicians experienced at least one symptom, such as emotional exhaustion, finding work no longer meaningful, feelings of ineffectiveness, and depersonalizing patients. Associated manifestations can range from headache and insomnia to impaired memory and decreased attention. 

meditation_1039533792_web2.jpg

Fast forward 10 years to the Medscape National Physician Burnout and Suicide Report, which found that a similar number of physicians (42%) feel burned out. The COVID-19 pandemic only added insult to injury. A Medscape survey that included nearly 5,000 U.S. physicians revealed that about two-thirds (64%) of them reported burnout had intensified during the crisis.

These elevated numbers are being labeled as “a public health crisis” for the impact widespread physician burnout could have on the health of the doctor and patient safety. The relatively consistent levels across the decade seem to suggest that, if health organizations are attempting to improve physician well-being, it doesn’t appear to be working, forcing doctors to find solutions for themselves.

Jill Wener, MD, considers herself part of the 45% burned out 10 years ago. She was working as an internist at Rush University Medical Center in Chicago, but the “existential reality of being a doctor in this world” was wearing on her. “Staying up with the literature, knowing that every day you’re going to go into work without knowing what you’re going to find, threats of lawsuits, the pressure of perfectionism,” Dr. Wener told this news organization. “By the time I hit burnout, everything made me feel like the world was crashing down on me.”

When Dr. Wener encountered someone who meditated twice a day, she was intrigued, even though the self-described “most Type-A, inside-the-box, nonspiritual type, anxious, linear-path doctor” didn’t think people like her could meditate. Dr. Wener is not alone in her hesitation to explore meditation as a means to help prevent burnout because the causes of burnout are primarily linked to external rather than internal factors. Issues including a loss of autonomy, the burden and distraction of electronic health records, and the intense pressure to comply with rules from the government are not things mindfulness can fix. 

Wener_Jill_GA_web2.jpg

And because the sources of burnout are primarily environmental and inherent to the current medical system, the suggestion that physicians need to fix themselves with meditation can come as a slap in the face. However, when up against a system slow to change, mindfulness can provide physicians access to the one thing they can control: How they perceive and react to what’s in front of them.

At the recommendation of an acquaintance, Dr. Wener enrolled in a Vedic Meditation (also known as Conscious Health Meditation) course taught by Light Watkins, a well-known traveling instructor, author, and speaker. By the second meeting she was successfully practicing 20 minutes twice a day. This form of mediation traces its roots to the Vedas, ancient Indian texts (also the foundation for yoga), and uses a mantra to settle the mind, transitioning to an awake state of inner contentment. 

Three weeks later, Dr. Wener’s daily crying jags ended as did her propensity for road rage. “I felt like I was on the cusp of something life-changing, I just didn’t understand it,” she recalled. “But I knew I was never going to give it up.”
 

Defining mindfulness

“Mindfulness is being able to be present in the moment that you’re in with acceptance of what it is and without judging it,” said Donna Rockwell, PsyD, a leading mindfulness meditation teacher. The practice of mindfulness is really meditation. Dr. Rockwell explained that the noise of our mind is most often focused on either the past or the future. “We’re either bemoaning something that happened earlier or we’re catastrophizing the future,” she said, which prevents us from being present in the moment. 

Meditation allows you to notice when your mind has drifted from the present moment into the past or future. “You gently notice it, label it with a lot of self-compassion, and then bring your mind back by focusing on your breath – going out, going in – and the incoming stimuli through your five senses,” said Dr. Rockwell. “When you’re doing that, you can’t be in the past or future.”

Dr. Rockwell also pointed out that we constantly categorize incoming data of the moment as either “good for me or bad for me,” which gets in the way of simply being present for what you’re facing. “When you’re more fully present, you become more skillful and able to do what this moment is asking of you,” she said. Being mindful allows us to better navigate incoming stimuli, which could be a “code blue” in the ED or a patient who needs another 2 minutes during an office visit. 

When Dr. Wener was burned out, she felt unable to adapt whenever something unexpected happened. “When you have no emotional reserves, everything feels like a big deal,” she said. “The meditation gave me what we call adaptation energy; it filled up my tank and kept me from feeling like I was going to lose it at 10 o’clock in the morning.”

Dr. Rockwell explained burnout as an overactive fight or flight response activated by the amygdala. It starts pumping cortisol, our pupils dilate, and our pores open. The prefrontal cortex is offline when we’re experiencing this physiological response because they both can’t be operational at the same time. “When we’re constantly in a ‘fight or flight’ response and don’t have any access to our prefrontal cortex, we are coming from a brain that is pumping cortisol and that leads to burnout,” said Dr. Rockwell.

“Any fight or flight response leaves a mark on your body,” Dr. Wener echoed. “When we go into our state of deep rest in the meditation practice, which is two to five times more restful than sleep, it heals those stress scars.”
 

Making time for mindfulness

Prescribing mindfulness for physicians is not new. Molecular biologist Jon Kabat-Zinn, PhD, developed Mindfulness-Based Stress Reduction (MBSR) in 1979, a practice that incorporates mindfulness exercises to help people become familiar with their behavior patterns in stressful situations. Thus, instead of reacting, they can respond with a clearer understanding of the circumstance. Dr. Kabat-Zinn initially targeted people with chronic health problems to help them cope with the effects of pain and the condition of their illness, but it has expanded to anyone experiencing challenges in their life, including physicians. A standard MBSR course runs 8 weeks, making it a commitment for most people. 

Mindfulness training requires that physicians use what they already have so little of: time.

Dr. Wener was able to take a sabbatical, embarking on a 3-month trip to India to immerse herself in the study of Vedic Meditation. Upon her return, Dr. Wener took a position at Emory University, Atlanta, and has launched a number of CME-accredited meditation courses and retreats. Unlike Dr. Kabat-Zinn, her programs are by physicians and for physicians. She also created an online version of the meditation course to make it more accessible. 

For these reasons, Kara Pepper, MD, an internist in outpatient primary care in Atlanta, was drawn to the meditation course. Dr. Pepper was 7 years into practice when she burned out. “The program dovetailed into my burnout recovery,” she said. “It allowed me space to separate myself from the thoughts I was having about work and just recognize them as just that – as thoughts.”

In the course, Dr. Wener teaches the REST Technique, which she says is different than mindfulness in that she encourages the mind to run rampant. “Trying to control the mind can feel very uncomfortable because we always have thoughts,” she says. “We can’t tell the mind to stop thinking just like we can’t tell the heart to stop beating.” Dr. Wener said the REST Technique lets “the mind swim downstream,” allowing the brain to go into a deep state of rest and start to heal from the scars caused by stress. 

Dr. Pepper said the self-paced online course gave her all the tools she needed, and it was pragmatic and evidence based. “I didn’t feel ‘woo’ or like another gimmick,” she said. Pepper, who continues to practice medicine, became a life coach in 2019 to teach others the skills she uses daily. 
 

An integrated strategy

Dr. Wener acknowledges that meditation is not the panacea for everyone’s burnout, which data support. In a review published in The American Journal of Medicine in 2019, Scott Yates, MD, MBA, from the Center for Executive Medicine in Plano, Tex., found that physicians who had adopted mediation and mindfulness training to decrease anxiety and perceived work stress only experienced modest benefits. In fact, Dr. Yates claims that there’s little data to suggest the long-term benefit of any particular stress management intervention in the prevention of burnout symptoms. 

“The often-repeated goals of the Triple Aim [enhancing patient experience, improving population health, and reducing costs] may be unreachable until we recognize and address burnout in health care providers,” Dr. Yates wrote. He recommends adding a fourth goal to specifically address physician wellness, which certainly could include mindfulness training and meditation.

Burnout coach, trainer, and consultant Dike Drummond, MD, also professes that physician wellness must be added as the key fourth ingredient to improving health care. “Burnout is a dilemma, a balancing act,” he said. “It takes an integrated strategy.” The CEO and founder of TheHappyMD.com, Dr. Drummond’s integrated strategy to stop physician burnout has been taught to more than 40,000 physicians in 175 organizations, and one element of that strategy can be mindfulness training. 

Dr. Drummond said he doesn’t use the word meditation “because that scares most people”; it takes a commitment and isn’t accessible for a lot of doctors. Instead, he coaches doctors to use a ‘single-breath’ technique to help them reset multiple times throughout the day. “I teach people how to breathe up to the top of their head and then down to the bottom of their feet,” Dr. Drummond said. He calls it the Squeegee Breath Technique because when they exhale, they “wipe away” anything that doesn’t need to be there right now. “If you happen to have a mindfulness practice like meditation, they work synergistically because the calmness you feel in your mediation is available to you at the bottom of these releasing breaths.”

Various studies and surveys provide great detail as to the “why” of physician burnout. And while mindfulness is not the sole answer, it’s something physicians can explore for themselves while health care as an industry looks for a more comprehensive solution. 

“It’s not rocket science,” Dr. Drummond insisted. “You want a different result? You’re not satisfied with the way things are now and you want to feel different? You absolutely must do something different.”

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

In 2011, the Mayo Clinic began surveying physicians about burnout and found 45% of physicians experienced at least one symptom, such as emotional exhaustion, finding work no longer meaningful, feelings of ineffectiveness, and depersonalizing patients. Associated manifestations can range from headache and insomnia to impaired memory and decreased attention. 

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Fast forward 10 years to the Medscape National Physician Burnout and Suicide Report, which found that a similar number of physicians (42%) feel burned out. The COVID-19 pandemic only added insult to injury. A Medscape survey that included nearly 5,000 U.S. physicians revealed that about two-thirds (64%) of them reported burnout had intensified during the crisis.

These elevated numbers are being labeled as “a public health crisis” for the impact widespread physician burnout could have on the health of the doctor and patient safety. The relatively consistent levels across the decade seem to suggest that, if health organizations are attempting to improve physician well-being, it doesn’t appear to be working, forcing doctors to find solutions for themselves.

Jill Wener, MD, considers herself part of the 45% burned out 10 years ago. She was working as an internist at Rush University Medical Center in Chicago, but the “existential reality of being a doctor in this world” was wearing on her. “Staying up with the literature, knowing that every day you’re going to go into work without knowing what you’re going to find, threats of lawsuits, the pressure of perfectionism,” Dr. Wener told this news organization. “By the time I hit burnout, everything made me feel like the world was crashing down on me.”

When Dr. Wener encountered someone who meditated twice a day, she was intrigued, even though the self-described “most Type-A, inside-the-box, nonspiritual type, anxious, linear-path doctor” didn’t think people like her could meditate. Dr. Wener is not alone in her hesitation to explore meditation as a means to help prevent burnout because the causes of burnout are primarily linked to external rather than internal factors. Issues including a loss of autonomy, the burden and distraction of electronic health records, and the intense pressure to comply with rules from the government are not things mindfulness can fix. 

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And because the sources of burnout are primarily environmental and inherent to the current medical system, the suggestion that physicians need to fix themselves with meditation can come as a slap in the face. However, when up against a system slow to change, mindfulness can provide physicians access to the one thing they can control: How they perceive and react to what’s in front of them.

At the recommendation of an acquaintance, Dr. Wener enrolled in a Vedic Meditation (also known as Conscious Health Meditation) course taught by Light Watkins, a well-known traveling instructor, author, and speaker. By the second meeting she was successfully practicing 20 minutes twice a day. This form of mediation traces its roots to the Vedas, ancient Indian texts (also the foundation for yoga), and uses a mantra to settle the mind, transitioning to an awake state of inner contentment. 

Three weeks later, Dr. Wener’s daily crying jags ended as did her propensity for road rage. “I felt like I was on the cusp of something life-changing, I just didn’t understand it,” she recalled. “But I knew I was never going to give it up.”
 

Defining mindfulness

“Mindfulness is being able to be present in the moment that you’re in with acceptance of what it is and without judging it,” said Donna Rockwell, PsyD, a leading mindfulness meditation teacher. The practice of mindfulness is really meditation. Dr. Rockwell explained that the noise of our mind is most often focused on either the past or the future. “We’re either bemoaning something that happened earlier or we’re catastrophizing the future,” she said, which prevents us from being present in the moment. 

Meditation allows you to notice when your mind has drifted from the present moment into the past or future. “You gently notice it, label it with a lot of self-compassion, and then bring your mind back by focusing on your breath – going out, going in – and the incoming stimuli through your five senses,” said Dr. Rockwell. “When you’re doing that, you can’t be in the past or future.”

Dr. Rockwell also pointed out that we constantly categorize incoming data of the moment as either “good for me or bad for me,” which gets in the way of simply being present for what you’re facing. “When you’re more fully present, you become more skillful and able to do what this moment is asking of you,” she said. Being mindful allows us to better navigate incoming stimuli, which could be a “code blue” in the ED or a patient who needs another 2 minutes during an office visit. 

When Dr. Wener was burned out, she felt unable to adapt whenever something unexpected happened. “When you have no emotional reserves, everything feels like a big deal,” she said. “The meditation gave me what we call adaptation energy; it filled up my tank and kept me from feeling like I was going to lose it at 10 o’clock in the morning.”

Dr. Rockwell explained burnout as an overactive fight or flight response activated by the amygdala. It starts pumping cortisol, our pupils dilate, and our pores open. The prefrontal cortex is offline when we’re experiencing this physiological response because they both can’t be operational at the same time. “When we’re constantly in a ‘fight or flight’ response and don’t have any access to our prefrontal cortex, we are coming from a brain that is pumping cortisol and that leads to burnout,” said Dr. Rockwell.

“Any fight or flight response leaves a mark on your body,” Dr. Wener echoed. “When we go into our state of deep rest in the meditation practice, which is two to five times more restful than sleep, it heals those stress scars.”
 

Making time for mindfulness

Prescribing mindfulness for physicians is not new. Molecular biologist Jon Kabat-Zinn, PhD, developed Mindfulness-Based Stress Reduction (MBSR) in 1979, a practice that incorporates mindfulness exercises to help people become familiar with their behavior patterns in stressful situations. Thus, instead of reacting, they can respond with a clearer understanding of the circumstance. Dr. Kabat-Zinn initially targeted people with chronic health problems to help them cope with the effects of pain and the condition of their illness, but it has expanded to anyone experiencing challenges in their life, including physicians. A standard MBSR course runs 8 weeks, making it a commitment for most people. 

Mindfulness training requires that physicians use what they already have so little of: time.

Dr. Wener was able to take a sabbatical, embarking on a 3-month trip to India to immerse herself in the study of Vedic Meditation. Upon her return, Dr. Wener took a position at Emory University, Atlanta, and has launched a number of CME-accredited meditation courses and retreats. Unlike Dr. Kabat-Zinn, her programs are by physicians and for physicians. She also created an online version of the meditation course to make it more accessible. 

For these reasons, Kara Pepper, MD, an internist in outpatient primary care in Atlanta, was drawn to the meditation course. Dr. Pepper was 7 years into practice when she burned out. “The program dovetailed into my burnout recovery,” she said. “It allowed me space to separate myself from the thoughts I was having about work and just recognize them as just that – as thoughts.”

In the course, Dr. Wener teaches the REST Technique, which she says is different than mindfulness in that she encourages the mind to run rampant. “Trying to control the mind can feel very uncomfortable because we always have thoughts,” she says. “We can’t tell the mind to stop thinking just like we can’t tell the heart to stop beating.” Dr. Wener said the REST Technique lets “the mind swim downstream,” allowing the brain to go into a deep state of rest and start to heal from the scars caused by stress. 

Dr. Pepper said the self-paced online course gave her all the tools she needed, and it was pragmatic and evidence based. “I didn’t feel ‘woo’ or like another gimmick,” she said. Pepper, who continues to practice medicine, became a life coach in 2019 to teach others the skills she uses daily. 
 

An integrated strategy

Dr. Wener acknowledges that meditation is not the panacea for everyone’s burnout, which data support. In a review published in The American Journal of Medicine in 2019, Scott Yates, MD, MBA, from the Center for Executive Medicine in Plano, Tex., found that physicians who had adopted mediation and mindfulness training to decrease anxiety and perceived work stress only experienced modest benefits. In fact, Dr. Yates claims that there’s little data to suggest the long-term benefit of any particular stress management intervention in the prevention of burnout symptoms. 

“The often-repeated goals of the Triple Aim [enhancing patient experience, improving population health, and reducing costs] may be unreachable until we recognize and address burnout in health care providers,” Dr. Yates wrote. He recommends adding a fourth goal to specifically address physician wellness, which certainly could include mindfulness training and meditation.

Burnout coach, trainer, and consultant Dike Drummond, MD, also professes that physician wellness must be added as the key fourth ingredient to improving health care. “Burnout is a dilemma, a balancing act,” he said. “It takes an integrated strategy.” The CEO and founder of TheHappyMD.com, Dr. Drummond’s integrated strategy to stop physician burnout has been taught to more than 40,000 physicians in 175 organizations, and one element of that strategy can be mindfulness training. 

Dr. Drummond said he doesn’t use the word meditation “because that scares most people”; it takes a commitment and isn’t accessible for a lot of doctors. Instead, he coaches doctors to use a ‘single-breath’ technique to help them reset multiple times throughout the day. “I teach people how to breathe up to the top of their head and then down to the bottom of their feet,” Dr. Drummond said. He calls it the Squeegee Breath Technique because when they exhale, they “wipe away” anything that doesn’t need to be there right now. “If you happen to have a mindfulness practice like meditation, they work synergistically because the calmness you feel in your mediation is available to you at the bottom of these releasing breaths.”

Various studies and surveys provide great detail as to the “why” of physician burnout. And while mindfulness is not the sole answer, it’s something physicians can explore for themselves while health care as an industry looks for a more comprehensive solution. 

“It’s not rocket science,” Dr. Drummond insisted. “You want a different result? You’re not satisfied with the way things are now and you want to feel different? You absolutely must do something different.”

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

Physicians, clinicians, providers, healers, and now heroes, are some of the names we have been given throughout history. These titles bring together a universal concept in medicine that all human beings deserve compassion, understanding, and care. However, as health care providers we forget to show ourselves the same compassion we bestow upon others.

Williams_Gwendolyn_VA_web.jpg

Self-compassion is a new way of relating to ourselves. As clinicians, we are trained investigators, delving deeper into what our patient is thinking and feeling. “Tell me more about that. How does that make you feel? That must have been (very painful/scary/frustrating).” These are a few statements we learned in patient interviewing to actively engage with patients, build rapport, solidify trust, validate their concerns, and ultimately obtain the information needed to diagnose and heal.

We know the importance of looking beyond the surface, as more often than not a deeper inspection reveals more to the story. We have uncovered cracks in the foundation, erosion of the roof, worn out siding, and a glimpse into the complexities that make up each individual. We look at our patients, loved ones, and the world with night-vision lenses to uncover what is deeper.

Clinicians are good at directing compassion toward others, but not as good at giving it to themselves.¹ Many health care providers may see self-compassion as soft, weak, selfish, or unnecessary. However, mindful self-compassion is a positive practice that opens a pathway for healing, personal growth, and protection against the negative consequences of self-judgment, isolation, anxiety, burnout, and depression.
 

What is self-compassion?

Kristin Neff, PhD, an associate professor in educational psychology at the University of Texas at Austin, was the first to academically define self-compassion. Self-compassion brings together three core elements – kindness, humanity, and mindfulness.² Self-compassion involves acting the same way toward yourself when you are having a difficult time as you would toward another person. Instead of mercilessly judging and criticizing yourself for self-perceived inadequacies or shortcomings, self-compassion allows you to ask yourself: “How can I give myself comfort and care in this moment?”

Mindfulness acknowledges a painful experience without resistance or judgment, while being present in the moment with things as they are. Self-compassion provides the emotional safety needed to mindfully open to our pain, disappointments, and defeats. Mindfulness and self-compassion both allow us to live with more acceptance toward ourselves and our lives. Mindfulness asks: “What am I experiencing right now?” Self-compassion asks: “What do I need right now?” When you feel compassion for yourself or another, you recognize that suffering, failure, and imperfection are all part of the shared human experience.
 

The physiology of self-compassion

When we practice self-compassion, we feel safe and cared for because there is a physiological pathway that explains this response. Self-compassion helps down-regulate the stress response (fight-flight-freeze). When we are triggered by a threat to our self-concept, we are likely to do one, two, or all of three things: we fight ourselves (self-criticism – often our first reaction when things go wrong), we flee from others (isolation), or we freeze (rumination).

Feeling threatened puts stress on the mind and body, and chronic stress leads to anxiety and depression, which hinders emotional and physical well-being. With self-criticism, we are both the attacker and the attacked. When we practice self-compassion, we are deactivating the threat-defense system and activating the care system, releasing oxytocin and endorphins, which reduce stress and increase feelings of safety and security.³
 

Why is self-compassion important to provider well-being?

Research has shown that individuals who are more self-compassionate tend to have greater happiness, life satisfaction, and motivation; better relationships and physical health; and less anxiety and depression. They also have the resilience needed to cope with stressful life events. The more we practice being kind and compassionate with ourselves, the more we’ll increase the habit of self-compassion, and extend compassion to our patients and loved ones in daily life.⁴

Why is self-compassion important? When we experience a setback at work or in life, we can become defensive, accuse others, or blame ourselves, especially when we are already under immense stress. These responses are not helpful, productive, or effective to the situation or our personal well-being. Although in the moment it may feel good to be reactive, it is a short-lived feeling that we trade for the longer-lasting effects of learning, resilience, and personal growth. Self-compassion teaches us to connect with our inner imperfections, and what makes us human, as to err is human.

To cultivate a habit of self-compassion itself, it is important to understand that self-compassion is a practice of goodwill, not good feelings. Self-compassion is aimed at the alleviation of suffering, but it does not erase any pain and suffering that does exist. The truth is, we can’t always control external forces – the events of 2020-2021 are a perfect example of this. As a result, we cannot utilize self-compassion as a practice to make our pain disappear or suppress strong emotions.

Instead, self-compassion helps us cultivate the resilience needed to mindfully acknowledge and accept a painful moment or experience, while reminding us to embrace ourselves with kindness and care in response. This builds our internal foundation with support, love, and self-care, while providing the optimal conditions for growth, resilience, and transformation
 

Self-compassion and the backdraft phenomenon

When you start the practice of self-compassion, you may experience backdraft, a phenomenon in which pain initially increases.⁵ Backdraft is similar to the stages of grief or when the flames of a burning house become larger when a door is opened and oxygen surges in. Practicing self-compassion may cause a tidal wave of emotions to come to the forefront, but it is likely that if this happens, it needs to happen.

Imagine yourself in a room with two versions of yourself. To the left is your best self that you present to the world, standing tall, organized, well kept, and without any noticeable imperfections. To the right, is the deepest part of your being, laying on the floor, filled with raw emotions – sadness, fear, anger, and love. This version of yourself is vulnerable, open, honest, and imperfect. When looking at each version of yourself, which one is the real you? The right? The left? Maybe it’s both?

Imagine what would happen if you walked over to the version of yourself on the right, sat down, and provided it comfort, and embraced yourself with love and kindness. What would happen if you gave that version of yourself a hug? Seeing your true self, with all the layers peeled away, at the very core of your being, vulnerable, and possibly broken, is a powerful and gut-wrenching experience. It may hurt at first, but once we embrace our own pain and suffering, that is where mindfulness and self-compassion intersect to begin the path to healing. It takes more strength and courage to be the version of ourselves on the right than the version on the left.
 

What is not self compassion?

Self-compassion is not self-pity, weakness, self-esteem, or selfishness. When individuals feel self-pity, they become immersed in their own problems and feel that they are the only ones in the world who are suffering. Self-compassion makes us more willing to accept, experience, and acknowledge difficult feelings with kindness. This paradoxically helps us process and let go of these feelings without long-term negative consequences, and with a better ability to recognize the suffering of others.

Self-compassion allows us to be our own inner ally and strengthens our ability to cope successfully when life gets hard. Self-compassion will not make you weak and vulnerable. It is a reliable source of inner strength that enhances resilience when faced with difficulties. Research shows self-compassionate people are better able to cope with tough situations like divorce, trauma, and crisis.

Self-compassion and self-esteem are important to well-being; however, they are not the same. Self-esteem refers to a judgment or evaluation of our sense of self-worth, perceived value, or how much we like ourselves. While self-compassion relates to the changing landscape of who we are with kindness and acceptance – especially in times when we feel useless, inadequate, or hopeless – self-esteem allows for greater self-clarity, independent of external circumstances, and acknowledges that all human beings deserve compassion and understanding, not because they possess certain traits or have a certain perceive valued, but because we share the human experience and the human condition of imperfection. Finally, self-compassion is not selfish, as practicing it helps people sustain the act of caring for others and decrease caregiver burnout.^6,7
 

Strategies to practice self-compassion

There are many ways to practice self-compassion. Here are a few experiences created by Dr. Neff, a leader in the field.⁸

Experience 1: How would you treat a friend?

How do you think things might change if you responded to yourself in the same way you typically respond to a close friend when he or she is suffering? Why not try treating yourself like a good friend and see what happens.

Take out a sheet of paper and write down your answer to the following questions:

• First, think about times when a close friend feels really bad about him or herself or is really struggling in some way. How would you respond to your friend in this situation (especially when you’re at your best)? Write down what you typically do and say and note the tone in which you typically talk to your friends.
• Second, think about times when you feel bad about yourself or are struggling. How do you typically respond to yourself in these situations? Write down what you typically do and say, and note the tone in which you typically talk to your friends.
• Did you notice a difference? If so, ask yourself why. What factors or fears come into play that lead you to treat yourself and others so differently?
• Please write down how you think things might change if you responded to yourself in the same way you typically respond to a close friend when you’re suffering.

Experience 2: Take a self-compassion break

This practice can be used any time of day or night, with others or alone. It will help you remember to evoke the three aspects of self-compassion when you need it most.

Think of a situation in your life that is difficult, that is causing you stress. Call the situation to mind, and if you feel comfortable, allow yourself to experience these feelings and emotions, without judgment and without altering them to what you think they should be.

• Say to yourself one of the following: “This is a difficult moment,” “This is a moment of suffering,” “This is stress,” “This hurts,” or “Ouch.” Doing this step is “mindfulness”: A willingness to observe negative thoughts and emotions with openness and clarity, so that they are held in mindful awareness, without judgment.
• Find your equilibrium of observation with thoughts and feelings. Try not to suppress or deny them and try not to get caught up and swept away by them.
• Remind yourself of the shared human experience. Recognize that suffering and personal difficulty is something that we all go through rather than being something that happens to “me” alone. Remind yourself that “other people feel this way,” “I’m not alone,” and “we all have struggles in life.”
• Be kind to yourself and ask: “What do I need to hear right now to express kindness to myself?” Is there a phrase that speaks to you in your particular situation? For example: “May I give myself the compassion that I need; may I learn to accept myself as I am; may I forgive myself; may I be strong; may I be patient.” There is no wrong answer.

Exercise 3: Explore self-compassion through writing

Everybody has something about themselves that they don’t like; something that causes them to feel shame, to feel insecure, or not “good enough.” This exercise will help you write a letter to yourself about this issue from a place of acceptance and compassion. It can feel uncomfortable at first, but it gets easier with practice.

• Write about an issue you have that makes you feel inadequate or bad about yourself (physical appearance, work, or relationship issue) What emotions do you experience when you think about this aspect of yourself? Try to only feel your emotions exactly as they are – no more, no less – and then write about them.
• Write a letter as if you were talking to a dearly beloved friend who was struggling with the same concerns as you and has the same strengths and weaknesses as you. How would you convey deep compassion, especially for the pain you feel when they judge themselves so harshly? What would you write to your friend to remind them that they are only human, that all people have both strengths and weaknesses? As you write, try to infuse your letter with a strong sense of acceptance, kindness, caring, and desire for their health and happiness.
• After writing the letter, put it aside for a little while. Then come back and read it again, really letting the words sink in. Feel the compassion as it pours into you, soothing and comforting you. Love, connection, and acceptance are a part of your human right. To claim them you need only look within yourself.

Experience 4: Taking care of the caregiver

We work in the very stressful time of the COVID pandemic. As medical providers, we are caregivers to our patients and our families. Yet, we do not give ourselves time to rest, recover, and recharge. Remember, to care for others, you cannot pour from an empty cup.

• Give yourself permission to meet your own needs, recognizing that this will not only enhance your quality of life, it will also enhance your ability to be there for those that rely on you. Our time is limited but self-care can occur both at work and outside of work.
• When you are “off the clock,” be off the clock! Turn off notifications, don’t check email, and be present in your personal lives. If you are constantly answering patient calls or nursing questions until 10 p.m., that means your health care system is in need of an upgrade, as you need the appropriate coverage to give you time to care for yourself, just as well as you care for your patients.
• While at work you can practice self-care. Take 2 minutes to practice relaxation breathing. Take 1 minute to show yourself or another person gratitude. Take 5 minutes before you start writing your notes for the day to listen to relaxing music or a mindful podcast. Take 3 minutes to share three good things that happened in the day with your family or colleagues. Take 5-10 minutes to do chair yoga. Take a self-compassion break.
• Implement a 5-minute wellness break into your group’s daily function with some of the previous mentioned examples. This will allow you to care for and nurture yourself, while also caring for and nurturing others in an environment that cultivates your wellness goals.

As a hospitalist, I can attest that I did not show myself self-compassion nearly as often as I showed compassion to others. I am my own worst critic and my training taught me to suffer in silence, and not seek out others who are experiencing the same thing for fear of being perceived as weak, inadequate, or flawed.

This false notion that we need to always be tough, strong, and without emotion in order to be taken seriously, to advance, or be held in high regard is rubbish and only perpetuated by accepting it. In order to change the culture of medicine, we have to change the way we think and behave. I have practiced self-compassion exercises and it has enhanced my perspective to see that many of us are going through varying degrees of the same thing. It has shown me the positive effects on my inner being and my life. If you are ready to try something new that will benefit your psychological and emotional well-being, and help you through pain, suffering, struggles, and crisis, you have nothing to lose. Be the change, and show yourself self-compassion.

In summary, self-compassion is an attitude of warmth, curiosity, connection, and care. Learning to become more self-compassionate is a process of moving from striving to change our experience and ourselves toward embracing who we are already.⁹ The practice of self-compassion is giving ourselves what we need in the moment. Even if we are not ready, or it is too painful to fully accept or embrace, we can still plant the seeds that will, with time and patience, grow and bloom.

When we are mindful of our struggles, when we respond to ourselves with compassion, kindness, and give ourselves support in times of difficulty, we learn to embrace ourselves and our lives, our inner and outer imperfections, and provide ourselves with the strength needed to thrive in the most precarious and difficult situations. With self-compassion, we give the world the best of us, instead of what is left of us.

Dr. Williams is vice president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as vice president of the medical executive committee.

References

1. Sanchez-Reilly S et al. Caring for oneself to care for others: Physicians and their self-care. J Community Support Oncol. 2013;11(2):75-81. doi: 10.12788/j.suponc.0003.

2. Neff K. Self-Compassion: An Alternative Conceptualization of a Healthy Attitude Toward Oneself. Self Identity. 2010;2(2):85-101. doi: 10.1080/15298860309032.

3. Neff K et al. The forest and the trees: Examining the association of self-compassion and its positive and negative components with psychological functioning. Self Identity. 2018;17(6):627-45. doi: 10.1080/15298868.2018.1436587.

4. Zessin U et al. The relationship between self-compassion and well-being: A meta-analysis. Appl Psychol Health Well-Being. 2015;7(3):340-64. doi: 10.1111/aphw.12051.

5. Warren R et al. Self-criticism and self-compassion: Risk and resilience. Current Psychiatry. 2016 Dec;15(12):18-21,24-28,32.

6. Neff K. The Five Myths of Self-Compassion. Greater Good Magazine. 2015 Sep 30. https://greatergood.berkeley.edu/article/item/the_five_myths_of_self_compassion.

7. Neff KD and Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013 Jan;69(1):28-44. doi: 10.1002/jclp.21923.

8. Neff K. Self-Compassion Guided Meditations and Exercises. https://self-compassion.org/category/exercises/#exercises.

9. Germer C and Neff KD. Mindful Self-Compassion (MSC), in “The handbook of mindfulness-based programs.” (London: Routledge, 2019, pp. 357-67).

Physicians, clinicians, providers, healers, and now heroes, are some of the names we have been given throughout history. These titles bring together a universal concept in medicine that all human beings deserve compassion, understanding, and care. However, as health care providers we forget to show ourselves the same compassion we bestow upon others.

Williams_Gwendolyn_VA_web.jpg

Self-compassion is a new way of relating to ourselves. As clinicians, we are trained investigators, delving deeper into what our patient is thinking and feeling. “Tell me more about that. How does that make you feel? That must have been (very painful/scary/frustrating).” These are a few statements we learned in patient interviewing to actively engage with patients, build rapport, solidify trust, validate their concerns, and ultimately obtain the information needed to diagnose and heal.

We know the importance of looking beyond the surface, as more often than not a deeper inspection reveals more to the story. We have uncovered cracks in the foundation, erosion of the roof, worn out siding, and a glimpse into the complexities that make up each individual. We look at our patients, loved ones, and the world with night-vision lenses to uncover what is deeper.

Clinicians are good at directing compassion toward others, but not as good at giving it to themselves.¹ Many health care providers may see self-compassion as soft, weak, selfish, or unnecessary. However, mindful self-compassion is a positive practice that opens a pathway for healing, personal growth, and protection against the negative consequences of self-judgment, isolation, anxiety, burnout, and depression.
 

What is self-compassion?

Kristin Neff, PhD, an associate professor in educational psychology at the University of Texas at Austin, was the first to academically define self-compassion. Self-compassion brings together three core elements – kindness, humanity, and mindfulness.² Self-compassion involves acting the same way toward yourself when you are having a difficult time as you would toward another person. Instead of mercilessly judging and criticizing yourself for self-perceived inadequacies or shortcomings, self-compassion allows you to ask yourself: “How can I give myself comfort and care in this moment?”

Mindfulness acknowledges a painful experience without resistance or judgment, while being present in the moment with things as they are. Self-compassion provides the emotional safety needed to mindfully open to our pain, disappointments, and defeats. Mindfulness and self-compassion both allow us to live with more acceptance toward ourselves and our lives. Mindfulness asks: “What am I experiencing right now?” Self-compassion asks: “What do I need right now?” When you feel compassion for yourself or another, you recognize that suffering, failure, and imperfection are all part of the shared human experience.
 

The physiology of self-compassion

When we practice self-compassion, we feel safe and cared for because there is a physiological pathway that explains this response. Self-compassion helps down-regulate the stress response (fight-flight-freeze). When we are triggered by a threat to our self-concept, we are likely to do one, two, or all of three things: we fight ourselves (self-criticism – often our first reaction when things go wrong), we flee from others (isolation), or we freeze (rumination).

Feeling threatened puts stress on the mind and body, and chronic stress leads to anxiety and depression, which hinders emotional and physical well-being. With self-criticism, we are both the attacker and the attacked. When we practice self-compassion, we are deactivating the threat-defense system and activating the care system, releasing oxytocin and endorphins, which reduce stress and increase feelings of safety and security.³
 

Why is self-compassion important to provider well-being?

Research has shown that individuals who are more self-compassionate tend to have greater happiness, life satisfaction, and motivation; better relationships and physical health; and less anxiety and depression. They also have the resilience needed to cope with stressful life events. The more we practice being kind and compassionate with ourselves, the more we’ll increase the habit of self-compassion, and extend compassion to our patients and loved ones in daily life.⁴

Why is self-compassion important? When we experience a setback at work or in life, we can become defensive, accuse others, or blame ourselves, especially when we are already under immense stress. These responses are not helpful, productive, or effective to the situation or our personal well-being. Although in the moment it may feel good to be reactive, it is a short-lived feeling that we trade for the longer-lasting effects of learning, resilience, and personal growth. Self-compassion teaches us to connect with our inner imperfections, and what makes us human, as to err is human.

To cultivate a habit of self-compassion itself, it is important to understand that self-compassion is a practice of goodwill, not good feelings. Self-compassion is aimed at the alleviation of suffering, but it does not erase any pain and suffering that does exist. The truth is, we can’t always control external forces – the events of 2020-2021 are a perfect example of this. As a result, we cannot utilize self-compassion as a practice to make our pain disappear or suppress strong emotions.

Instead, self-compassion helps us cultivate the resilience needed to mindfully acknowledge and accept a painful moment or experience, while reminding us to embrace ourselves with kindness and care in response. This builds our internal foundation with support, love, and self-care, while providing the optimal conditions for growth, resilience, and transformation
 

Self-compassion and the backdraft phenomenon

When you start the practice of self-compassion, you may experience backdraft, a phenomenon in which pain initially increases.⁵ Backdraft is similar to the stages of grief or when the flames of a burning house become larger when a door is opened and oxygen surges in. Practicing self-compassion may cause a tidal wave of emotions to come to the forefront, but it is likely that if this happens, it needs to happen.

Imagine yourself in a room with two versions of yourself. To the left is your best self that you present to the world, standing tall, organized, well kept, and without any noticeable imperfections. To the right, is the deepest part of your being, laying on the floor, filled with raw emotions – sadness, fear, anger, and love. This version of yourself is vulnerable, open, honest, and imperfect. When looking at each version of yourself, which one is the real you? The right? The left? Maybe it’s both?

Imagine what would happen if you walked over to the version of yourself on the right, sat down, and provided it comfort, and embraced yourself with love and kindness. What would happen if you gave that version of yourself a hug? Seeing your true self, with all the layers peeled away, at the very core of your being, vulnerable, and possibly broken, is a powerful and gut-wrenching experience. It may hurt at first, but once we embrace our own pain and suffering, that is where mindfulness and self-compassion intersect to begin the path to healing. It takes more strength and courage to be the version of ourselves on the right than the version on the left.
 

What is not self compassion?

Self-compassion is not self-pity, weakness, self-esteem, or selfishness. When individuals feel self-pity, they become immersed in their own problems and feel that they are the only ones in the world who are suffering. Self-compassion makes us more willing to accept, experience, and acknowledge difficult feelings with kindness. This paradoxically helps us process and let go of these feelings without long-term negative consequences, and with a better ability to recognize the suffering of others.

Self-compassion allows us to be our own inner ally and strengthens our ability to cope successfully when life gets hard. Self-compassion will not make you weak and vulnerable. It is a reliable source of inner strength that enhances resilience when faced with difficulties. Research shows self-compassionate people are better able to cope with tough situations like divorce, trauma, and crisis.

Self-compassion and self-esteem are important to well-being; however, they are not the same. Self-esteem refers to a judgment or evaluation of our sense of self-worth, perceived value, or how much we like ourselves. While self-compassion relates to the changing landscape of who we are with kindness and acceptance – especially in times when we feel useless, inadequate, or hopeless – self-esteem allows for greater self-clarity, independent of external circumstances, and acknowledges that all human beings deserve compassion and understanding, not because they possess certain traits or have a certain perceive valued, but because we share the human experience and the human condition of imperfection. Finally, self-compassion is not selfish, as practicing it helps people sustain the act of caring for others and decrease caregiver burnout.^6,7
 

Strategies to practice self-compassion

There are many ways to practice self-compassion. Here are a few experiences created by Dr. Neff, a leader in the field.⁸

Experience 1: How would you treat a friend?

How do you think things might change if you responded to yourself in the same way you typically respond to a close friend when he or she is suffering? Why not try treating yourself like a good friend and see what happens.

Take out a sheet of paper and write down your answer to the following questions:

• First, think about times when a close friend feels really bad about him or herself or is really struggling in some way. How would you respond to your friend in this situation (especially when you’re at your best)? Write down what you typically do and say and note the tone in which you typically talk to your friends.
• Second, think about times when you feel bad about yourself or are struggling. How do you typically respond to yourself in these situations? Write down what you typically do and say, and note the tone in which you typically talk to your friends.
• Did you notice a difference? If so, ask yourself why. What factors or fears come into play that lead you to treat yourself and others so differently?
• Please write down how you think things might change if you responded to yourself in the same way you typically respond to a close friend when you’re suffering.

Experience 2: Take a self-compassion break

This practice can be used any time of day or night, with others or alone. It will help you remember to evoke the three aspects of self-compassion when you need it most.

Think of a situation in your life that is difficult, that is causing you stress. Call the situation to mind, and if you feel comfortable, allow yourself to experience these feelings and emotions, without judgment and without altering them to what you think they should be.

• Say to yourself one of the following: “This is a difficult moment,” “This is a moment of suffering,” “This is stress,” “This hurts,” or “Ouch.” Doing this step is “mindfulness”: A willingness to observe negative thoughts and emotions with openness and clarity, so that they are held in mindful awareness, without judgment.
• Find your equilibrium of observation with thoughts and feelings. Try not to suppress or deny them and try not to get caught up and swept away by them.
• Remind yourself of the shared human experience. Recognize that suffering and personal difficulty is something that we all go through rather than being something that happens to “me” alone. Remind yourself that “other people feel this way,” “I’m not alone,” and “we all have struggles in life.”
• Be kind to yourself and ask: “What do I need to hear right now to express kindness to myself?” Is there a phrase that speaks to you in your particular situation? For example: “May I give myself the compassion that I need; may I learn to accept myself as I am; may I forgive myself; may I be strong; may I be patient.” There is no wrong answer.

Exercise 3: Explore self-compassion through writing

Everybody has something about themselves that they don’t like; something that causes them to feel shame, to feel insecure, or not “good enough.” This exercise will help you write a letter to yourself about this issue from a place of acceptance and compassion. It can feel uncomfortable at first, but it gets easier with practice.

• Write about an issue you have that makes you feel inadequate or bad about yourself (physical appearance, work, or relationship issue) What emotions do you experience when you think about this aspect of yourself? Try to only feel your emotions exactly as they are – no more, no less – and then write about them.
• Write a letter as if you were talking to a dearly beloved friend who was struggling with the same concerns as you and has the same strengths and weaknesses as you. How would you convey deep compassion, especially for the pain you feel when they judge themselves so harshly? What would you write to your friend to remind them that they are only human, that all people have both strengths and weaknesses? As you write, try to infuse your letter with a strong sense of acceptance, kindness, caring, and desire for their health and happiness.
• After writing the letter, put it aside for a little while. Then come back and read it again, really letting the words sink in. Feel the compassion as it pours into you, soothing and comforting you. Love, connection, and acceptance are a part of your human right. To claim them you need only look within yourself.

Experience 4: Taking care of the caregiver

We work in the very stressful time of the COVID pandemic. As medical providers, we are caregivers to our patients and our families. Yet, we do not give ourselves time to rest, recover, and recharge. Remember, to care for others, you cannot pour from an empty cup.

• Give yourself permission to meet your own needs, recognizing that this will not only enhance your quality of life, it will also enhance your ability to be there for those that rely on you. Our time is limited but self-care can occur both at work and outside of work.
• When you are “off the clock,” be off the clock! Turn off notifications, don’t check email, and be present in your personal lives. If you are constantly answering patient calls or nursing questions until 10 p.m., that means your health care system is in need of an upgrade, as you need the appropriate coverage to give you time to care for yourself, just as well as you care for your patients.
• While at work you can practice self-care. Take 2 minutes to practice relaxation breathing. Take 1 minute to show yourself or another person gratitude. Take 5 minutes before you start writing your notes for the day to listen to relaxing music or a mindful podcast. Take 3 minutes to share three good things that happened in the day with your family or colleagues. Take 5-10 minutes to do chair yoga. Take a self-compassion break.
• Implement a 5-minute wellness break into your group’s daily function with some of the previous mentioned examples. This will allow you to care for and nurture yourself, while also caring for and nurturing others in an environment that cultivates your wellness goals.

As a hospitalist, I can attest that I did not show myself self-compassion nearly as often as I showed compassion to others. I am my own worst critic and my training taught me to suffer in silence, and not seek out others who are experiencing the same thing for fear of being perceived as weak, inadequate, or flawed.

This false notion that we need to always be tough, strong, and without emotion in order to be taken seriously, to advance, or be held in high regard is rubbish and only perpetuated by accepting it. In order to change the culture of medicine, we have to change the way we think and behave. I have practiced self-compassion exercises and it has enhanced my perspective to see that many of us are going through varying degrees of the same thing. It has shown me the positive effects on my inner being and my life. If you are ready to try something new that will benefit your psychological and emotional well-being, and help you through pain, suffering, struggles, and crisis, you have nothing to lose. Be the change, and show yourself self-compassion.

In summary, self-compassion is an attitude of warmth, curiosity, connection, and care. Learning to become more self-compassionate is a process of moving from striving to change our experience and ourselves toward embracing who we are already.⁹ The practice of self-compassion is giving ourselves what we need in the moment. Even if we are not ready, or it is too painful to fully accept or embrace, we can still plant the seeds that will, with time and patience, grow and bloom.

When we are mindful of our struggles, when we respond to ourselves with compassion, kindness, and give ourselves support in times of difficulty, we learn to embrace ourselves and our lives, our inner and outer imperfections, and provide ourselves with the strength needed to thrive in the most precarious and difficult situations. With self-compassion, we give the world the best of us, instead of what is left of us.

Dr. Williams is vice president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as vice president of the medical executive committee.

References

1. Sanchez-Reilly S et al. Caring for oneself to care for others: Physicians and their self-care. J Community Support Oncol. 2013;11(2):75-81. doi: 10.12788/j.suponc.0003.

2. Neff K. Self-Compassion: An Alternative Conceptualization of a Healthy Attitude Toward Oneself. Self Identity. 2010;2(2):85-101. doi: 10.1080/15298860309032.

3. Neff K et al. The forest and the trees: Examining the association of self-compassion and its positive and negative components with psychological functioning. Self Identity. 2018;17(6):627-45. doi: 10.1080/15298868.2018.1436587.

4. Zessin U et al. The relationship between self-compassion and well-being: A meta-analysis. Appl Psychol Health Well-Being. 2015;7(3):340-64. doi: 10.1111/aphw.12051.

5. Warren R et al. Self-criticism and self-compassion: Risk and resilience. Current Psychiatry. 2016 Dec;15(12):18-21,24-28,32.

6. Neff K. The Five Myths of Self-Compassion. Greater Good Magazine. 2015 Sep 30. https://greatergood.berkeley.edu/article/item/the_five_myths_of_self_compassion.

7. Neff KD and Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013 Jan;69(1):28-44. doi: 10.1002/jclp.21923.

8. Neff K. Self-Compassion Guided Meditations and Exercises. https://self-compassion.org/category/exercises/#exercises.

9. Germer C and Neff KD. Mindful Self-Compassion (MSC), in “The handbook of mindfulness-based programs.” (London: Routledge, 2019, pp. 357-67).

Physicians, clinicians, providers, healers, and now heroes, are some of the names we have been given throughout history. These titles bring together a universal concept in medicine that all human beings deserve compassion, understanding, and care. However, as health care providers we forget to show ourselves the same compassion we bestow upon others.

Williams_Gwendolyn_VA_web.jpg

Self-compassion is a new way of relating to ourselves. As clinicians, we are trained investigators, delving deeper into what our patient is thinking and feeling. “Tell me more about that. How does that make you feel? That must have been (very painful/scary/frustrating).” These are a few statements we learned in patient interviewing to actively engage with patients, build rapport, solidify trust, validate their concerns, and ultimately obtain the information needed to diagnose and heal.

We know the importance of looking beyond the surface, as more often than not a deeper inspection reveals more to the story. We have uncovered cracks in the foundation, erosion of the roof, worn out siding, and a glimpse into the complexities that make up each individual. We look at our patients, loved ones, and the world with night-vision lenses to uncover what is deeper.

Clinicians are good at directing compassion toward others, but not as good at giving it to themselves.¹ Many health care providers may see self-compassion as soft, weak, selfish, or unnecessary. However, mindful self-compassion is a positive practice that opens a pathway for healing, personal growth, and protection against the negative consequences of self-judgment, isolation, anxiety, burnout, and depression.
 

What is self-compassion?

Kristin Neff, PhD, an associate professor in educational psychology at the University of Texas at Austin, was the first to academically define self-compassion. Self-compassion brings together three core elements – kindness, humanity, and mindfulness.² Self-compassion involves acting the same way toward yourself when you are having a difficult time as you would toward another person. Instead of mercilessly judging and criticizing yourself for self-perceived inadequacies or shortcomings, self-compassion allows you to ask yourself: “How can I give myself comfort and care in this moment?”

Mindfulness acknowledges a painful experience without resistance or judgment, while being present in the moment with things as they are. Self-compassion provides the emotional safety needed to mindfully open to our pain, disappointments, and defeats. Mindfulness and self-compassion both allow us to live with more acceptance toward ourselves and our lives. Mindfulness asks: “What am I experiencing right now?” Self-compassion asks: “What do I need right now?” When you feel compassion for yourself or another, you recognize that suffering, failure, and imperfection are all part of the shared human experience.
 

The physiology of self-compassion

When we practice self-compassion, we feel safe and cared for because there is a physiological pathway that explains this response. Self-compassion helps down-regulate the stress response (fight-flight-freeze). When we are triggered by a threat to our self-concept, we are likely to do one, two, or all of three things: we fight ourselves (self-criticism – often our first reaction when things go wrong), we flee from others (isolation), or we freeze (rumination).

Feeling threatened puts stress on the mind and body, and chronic stress leads to anxiety and depression, which hinders emotional and physical well-being. With self-criticism, we are both the attacker and the attacked. When we practice self-compassion, we are deactivating the threat-defense system and activating the care system, releasing oxytocin and endorphins, which reduce stress and increase feelings of safety and security.³
 

Why is self-compassion important to provider well-being?

Research has shown that individuals who are more self-compassionate tend to have greater happiness, life satisfaction, and motivation; better relationships and physical health; and less anxiety and depression. They also have the resilience needed to cope with stressful life events. The more we practice being kind and compassionate with ourselves, the more we’ll increase the habit of self-compassion, and extend compassion to our patients and loved ones in daily life.⁴

Why is self-compassion important? When we experience a setback at work or in life, we can become defensive, accuse others, or blame ourselves, especially when we are already under immense stress. These responses are not helpful, productive, or effective to the situation or our personal well-being. Although in the moment it may feel good to be reactive, it is a short-lived feeling that we trade for the longer-lasting effects of learning, resilience, and personal growth. Self-compassion teaches us to connect with our inner imperfections, and what makes us human, as to err is human.

To cultivate a habit of self-compassion itself, it is important to understand that self-compassion is a practice of goodwill, not good feelings. Self-compassion is aimed at the alleviation of suffering, but it does not erase any pain and suffering that does exist. The truth is, we can’t always control external forces – the events of 2020-2021 are a perfect example of this. As a result, we cannot utilize self-compassion as a practice to make our pain disappear or suppress strong emotions.

Instead, self-compassion helps us cultivate the resilience needed to mindfully acknowledge and accept a painful moment or experience, while reminding us to embrace ourselves with kindness and care in response. This builds our internal foundation with support, love, and self-care, while providing the optimal conditions for growth, resilience, and transformation
 

Self-compassion and the backdraft phenomenon

When you start the practice of self-compassion, you may experience backdraft, a phenomenon in which pain initially increases.⁵ Backdraft is similar to the stages of grief or when the flames of a burning house become larger when a door is opened and oxygen surges in. Practicing self-compassion may cause a tidal wave of emotions to come to the forefront, but it is likely that if this happens, it needs to happen.

Imagine yourself in a room with two versions of yourself. To the left is your best self that you present to the world, standing tall, organized, well kept, and without any noticeable imperfections. To the right, is the deepest part of your being, laying on the floor, filled with raw emotions – sadness, fear, anger, and love. This version of yourself is vulnerable, open, honest, and imperfect. When looking at each version of yourself, which one is the real you? The right? The left? Maybe it’s both?

Imagine what would happen if you walked over to the version of yourself on the right, sat down, and provided it comfort, and embraced yourself with love and kindness. What would happen if you gave that version of yourself a hug? Seeing your true self, with all the layers peeled away, at the very core of your being, vulnerable, and possibly broken, is a powerful and gut-wrenching experience. It may hurt at first, but once we embrace our own pain and suffering, that is where mindfulness and self-compassion intersect to begin the path to healing. It takes more strength and courage to be the version of ourselves on the right than the version on the left.
 

What is not self compassion?

Self-compassion is not self-pity, weakness, self-esteem, or selfishness. When individuals feel self-pity, they become immersed in their own problems and feel that they are the only ones in the world who are suffering. Self-compassion makes us more willing to accept, experience, and acknowledge difficult feelings with kindness. This paradoxically helps us process and let go of these feelings without long-term negative consequences, and with a better ability to recognize the suffering of others.

Self-compassion allows us to be our own inner ally and strengthens our ability to cope successfully when life gets hard. Self-compassion will not make you weak and vulnerable. It is a reliable source of inner strength that enhances resilience when faced with difficulties. Research shows self-compassionate people are better able to cope with tough situations like divorce, trauma, and crisis.

Self-compassion and self-esteem are important to well-being; however, they are not the same. Self-esteem refers to a judgment or evaluation of our sense of self-worth, perceived value, or how much we like ourselves. While self-compassion relates to the changing landscape of who we are with kindness and acceptance – especially in times when we feel useless, inadequate, or hopeless – self-esteem allows for greater self-clarity, independent of external circumstances, and acknowledges that all human beings deserve compassion and understanding, not because they possess certain traits or have a certain perceive valued, but because we share the human experience and the human condition of imperfection. Finally, self-compassion is not selfish, as practicing it helps people sustain the act of caring for others and decrease caregiver burnout.^6,7
 

Strategies to practice self-compassion

There are many ways to practice self-compassion. Here are a few experiences created by Dr. Neff, a leader in the field.⁸

Experience 1: How would you treat a friend?

How do you think things might change if you responded to yourself in the same way you typically respond to a close friend when he or she is suffering? Why not try treating yourself like a good friend and see what happens.

Take out a sheet of paper and write down your answer to the following questions:

• First, think about times when a close friend feels really bad about him or herself or is really struggling in some way. How would you respond to your friend in this situation (especially when you’re at your best)? Write down what you typically do and say and note the tone in which you typically talk to your friends.
• Second, think about times when you feel bad about yourself or are struggling. How do you typically respond to yourself in these situations? Write down what you typically do and say, and note the tone in which you typically talk to your friends.
• Did you notice a difference? If so, ask yourself why. What factors or fears come into play that lead you to treat yourself and others so differently?
• Please write down how you think things might change if you responded to yourself in the same way you typically respond to a close friend when you’re suffering.

Experience 2: Take a self-compassion break

This practice can be used any time of day or night, with others or alone. It will help you remember to evoke the three aspects of self-compassion when you need it most.

Think of a situation in your life that is difficult, that is causing you stress. Call the situation to mind, and if you feel comfortable, allow yourself to experience these feelings and emotions, without judgment and without altering them to what you think they should be.

• Say to yourself one of the following: “This is a difficult moment,” “This is a moment of suffering,” “This is stress,” “This hurts,” or “Ouch.” Doing this step is “mindfulness”: A willingness to observe negative thoughts and emotions with openness and clarity, so that they are held in mindful awareness, without judgment.
• Find your equilibrium of observation with thoughts and feelings. Try not to suppress or deny them and try not to get caught up and swept away by them.
• Remind yourself of the shared human experience. Recognize that suffering and personal difficulty is something that we all go through rather than being something that happens to “me” alone. Remind yourself that “other people feel this way,” “I’m not alone,” and “we all have struggles in life.”
• Be kind to yourself and ask: “What do I need to hear right now to express kindness to myself?” Is there a phrase that speaks to you in your particular situation? For example: “May I give myself the compassion that I need; may I learn to accept myself as I am; may I forgive myself; may I be strong; may I be patient.” There is no wrong answer.

Exercise 3: Explore self-compassion through writing

Everybody has something about themselves that they don’t like; something that causes them to feel shame, to feel insecure, or not “good enough.” This exercise will help you write a letter to yourself about this issue from a place of acceptance and compassion. It can feel uncomfortable at first, but it gets easier with practice.

• Write about an issue you have that makes you feel inadequate or bad about yourself (physical appearance, work, or relationship issue) What emotions do you experience when you think about this aspect of yourself? Try to only feel your emotions exactly as they are – no more, no less – and then write about them.
• Write a letter as if you were talking to a dearly beloved friend who was struggling with the same concerns as you and has the same strengths and weaknesses as you. How would you convey deep compassion, especially for the pain you feel when they judge themselves so harshly? What would you write to your friend to remind them that they are only human, that all people have both strengths and weaknesses? As you write, try to infuse your letter with a strong sense of acceptance, kindness, caring, and desire for their health and happiness.
• After writing the letter, put it aside for a little while. Then come back and read it again, really letting the words sink in. Feel the compassion as it pours into you, soothing and comforting you. Love, connection, and acceptance are a part of your human right. To claim them you need only look within yourself.

Experience 4: Taking care of the caregiver

We work in the very stressful time of the COVID pandemic. As medical providers, we are caregivers to our patients and our families. Yet, we do not give ourselves time to rest, recover, and recharge. Remember, to care for others, you cannot pour from an empty cup.

• Give yourself permission to meet your own needs, recognizing that this will not only enhance your quality of life, it will also enhance your ability to be there for those that rely on you. Our time is limited but self-care can occur both at work and outside of work.
• When you are “off the clock,” be off the clock! Turn off notifications, don’t check email, and be present in your personal lives. If you are constantly answering patient calls or nursing questions until 10 p.m., that means your health care system is in need of an upgrade, as you need the appropriate coverage to give you time to care for yourself, just as well as you care for your patients.
• While at work you can practice self-care. Take 2 minutes to practice relaxation breathing. Take 1 minute to show yourself or another person gratitude. Take 5 minutes before you start writing your notes for the day to listen to relaxing music or a mindful podcast. Take 3 minutes to share three good things that happened in the day with your family or colleagues. Take 5-10 minutes to do chair yoga. Take a self-compassion break.
• Implement a 5-minute wellness break into your group’s daily function with some of the previous mentioned examples. This will allow you to care for and nurture yourself, while also caring for and nurturing others in an environment that cultivates your wellness goals.

As a hospitalist, I can attest that I did not show myself self-compassion nearly as often as I showed compassion to others. I am my own worst critic and my training taught me to suffer in silence, and not seek out others who are experiencing the same thing for fear of being perceived as weak, inadequate, or flawed.

This false notion that we need to always be tough, strong, and without emotion in order to be taken seriously, to advance, or be held in high regard is rubbish and only perpetuated by accepting it. In order to change the culture of medicine, we have to change the way we think and behave. I have practiced self-compassion exercises and it has enhanced my perspective to see that many of us are going through varying degrees of the same thing. It has shown me the positive effects on my inner being and my life. If you are ready to try something new that will benefit your psychological and emotional well-being, and help you through pain, suffering, struggles, and crisis, you have nothing to lose. Be the change, and show yourself self-compassion.

In summary, self-compassion is an attitude of warmth, curiosity, connection, and care. Learning to become more self-compassionate is a process of moving from striving to change our experience and ourselves toward embracing who we are already.⁹ The practice of self-compassion is giving ourselves what we need in the moment. Even if we are not ready, or it is too painful to fully accept or embrace, we can still plant the seeds that will, with time and patience, grow and bloom.

When we are mindful of our struggles, when we respond to ourselves with compassion, kindness, and give ourselves support in times of difficulty, we learn to embrace ourselves and our lives, our inner and outer imperfections, and provide ourselves with the strength needed to thrive in the most precarious and difficult situations. With self-compassion, we give the world the best of us, instead of what is left of us.

Dr. Williams is vice president of the Hampton Roads chapter of the Society of Hospital Medicine. She is a hospitalist at Sentara Careplex Hospital in Hampton, Va., where she also serves as vice president of the medical executive committee.

References

1. Sanchez-Reilly S et al. Caring for oneself to care for others: Physicians and their self-care. J Community Support Oncol. 2013;11(2):75-81. doi: 10.12788/j.suponc.0003.

2. Neff K. Self-Compassion: An Alternative Conceptualization of a Healthy Attitude Toward Oneself. Self Identity. 2010;2(2):85-101. doi: 10.1080/15298860309032.

3. Neff K et al. The forest and the trees: Examining the association of self-compassion and its positive and negative components with psychological functioning. Self Identity. 2018;17(6):627-45. doi: 10.1080/15298868.2018.1436587.

4. Zessin U et al. The relationship between self-compassion and well-being: A meta-analysis. Appl Psychol Health Well-Being. 2015;7(3):340-64. doi: 10.1111/aphw.12051.

5. Warren R et al. Self-criticism and self-compassion: Risk and resilience. Current Psychiatry. 2016 Dec;15(12):18-21,24-28,32.

6. Neff K. The Five Myths of Self-Compassion. Greater Good Magazine. 2015 Sep 30. https://greatergood.berkeley.edu/article/item/the_five_myths_of_self_compassion.

7. Neff KD and Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013 Jan;69(1):28-44. doi: 10.1002/jclp.21923.

8. Neff K. Self-Compassion Guided Meditations and Exercises. https://self-compassion.org/category/exercises/#exercises.

9. Germer C and Neff KD. Mindful Self-Compassion (MSC), in “The handbook of mindfulness-based programs.” (London: Routledge, 2019, pp. 357-67).

Total COVID-19 cases in children surpassed the 7-million mark as new cases rose slightly after the previous week’s decline, according to the American Academy of Pediatrics and the Children’s Hospital Association.

155360_graphic_web.png

The 133,000 new cases reported for the week ending Dec. 2 mark the 17th consecutive week that the count has exceeded 100,000 and brought the cumulative national count to 7.03 million since the start of the pandemic, the AAP and CHA said in their weekly COVID-19 report. New cases had dropped the previous week after 3 straight weeks of increases since late October.

The Centers for Disease Control and Prevention puts the total number of child COVID-19 cases at 6.2 million, but both estimates are based on all-age totals – 40 million for the CDC and 41 million for the AAP/CHA – that are well short of the CDC’s latest cumulative figure, which is now just over 49 million, so the actual figures are undoubtedly higher.

Meanwhile, the 1-month anniversary of 5- to 11-year-olds’ vaccine eligibility brought many completions: 923,000 received their second dose during the week ending Dec. 6, compared with 405,000 the previous week. About 16.9% (4.9 million) of children aged 5-11 have gotten at least one dose of the COVID-19 vaccine thus far, of whom almost 1.5 million children (5.1% of the age group) are now fully vaccinated, the CDC said on its COVID-19 Data Tracker.

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The pace of vaccinations, however, is much lower for older children. Weekly numbers for all COVID-19 vaccinations, both first and second doses, dropped from 84,000 (Nov. 23-29) to 70,000 (Nov. 30 to Dec. 6), for those aged 12-17 years. In that group, 61.6% have received at least one dose and 51.8% are fully vaccinated, the CDC said.

The pace of vaccinations varies for younger children as well, when geography is considered. The AAP analyzed the CDC’s data and found that 42% of all 5- to 11-year-olds in Vermont had received at least one dose as of Dec. 1, followed by Massachusetts (33%), Maine (30%), and Rhode Island (28%). At the other end of the vaccination scale are Alabama, Louisiana, Mississippi, and West Virginia, all with 4%, the AAP reported.

As the United States puts 7 million children infected with COVID-19 in its rear view mirror, another milestone is looming ahead: The CDC’s current count of deaths in children is 974.

rfranki@mdedge.com

Total COVID-19 cases in children surpassed the 7-million mark as new cases rose slightly after the previous week’s decline, according to the American Academy of Pediatrics and the Children’s Hospital Association.

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The 133,000 new cases reported for the week ending Dec. 2 mark the 17th consecutive week that the count has exceeded 100,000 and brought the cumulative national count to 7.03 million since the start of the pandemic, the AAP and CHA said in their weekly COVID-19 report. New cases had dropped the previous week after 3 straight weeks of increases since late October.

The Centers for Disease Control and Prevention puts the total number of child COVID-19 cases at 6.2 million, but both estimates are based on all-age totals – 40 million for the CDC and 41 million for the AAP/CHA – that are well short of the CDC’s latest cumulative figure, which is now just over 49 million, so the actual figures are undoubtedly higher.

Meanwhile, the 1-month anniversary of 5- to 11-year-olds’ vaccine eligibility brought many completions: 923,000 received their second dose during the week ending Dec. 6, compared with 405,000 the previous week. About 16.9% (4.9 million) of children aged 5-11 have gotten at least one dose of the COVID-19 vaccine thus far, of whom almost 1.5 million children (5.1% of the age group) are now fully vaccinated, the CDC said on its COVID-19 Data Tracker.

[embed:render:related:node:249299]

The pace of vaccinations, however, is much lower for older children. Weekly numbers for all COVID-19 vaccinations, both first and second doses, dropped from 84,000 (Nov. 23-29) to 70,000 (Nov. 30 to Dec. 6), for those aged 12-17 years. In that group, 61.6% have received at least one dose and 51.8% are fully vaccinated, the CDC said.

The pace of vaccinations varies for younger children as well, when geography is considered. The AAP analyzed the CDC’s data and found that 42% of all 5- to 11-year-olds in Vermont had received at least one dose as of Dec. 1, followed by Massachusetts (33%), Maine (30%), and Rhode Island (28%). At the other end of the vaccination scale are Alabama, Louisiana, Mississippi, and West Virginia, all with 4%, the AAP reported.

As the United States puts 7 million children infected with COVID-19 in its rear view mirror, another milestone is looming ahead: The CDC’s current count of deaths in children is 974.

rfranki@mdedge.com

Total COVID-19 cases in children surpassed the 7-million mark as new cases rose slightly after the previous week’s decline, according to the American Academy of Pediatrics and the Children’s Hospital Association.

155360_graphic_web.png

The 133,000 new cases reported for the week ending Dec. 2 mark the 17th consecutive week that the count has exceeded 100,000 and brought the cumulative national count to 7.03 million since the start of the pandemic, the AAP and CHA said in their weekly COVID-19 report. New cases had dropped the previous week after 3 straight weeks of increases since late October.

The Centers for Disease Control and Prevention puts the total number of child COVID-19 cases at 6.2 million, but both estimates are based on all-age totals – 40 million for the CDC and 41 million for the AAP/CHA – that are well short of the CDC’s latest cumulative figure, which is now just over 49 million, so the actual figures are undoubtedly higher.

Meanwhile, the 1-month anniversary of 5- to 11-year-olds’ vaccine eligibility brought many completions: 923,000 received their second dose during the week ending Dec. 6, compared with 405,000 the previous week. About 16.9% (4.9 million) of children aged 5-11 have gotten at least one dose of the COVID-19 vaccine thus far, of whom almost 1.5 million children (5.1% of the age group) are now fully vaccinated, the CDC said on its COVID-19 Data Tracker.

[embed:render:related:node:249299]

The pace of vaccinations, however, is much lower for older children. Weekly numbers for all COVID-19 vaccinations, both first and second doses, dropped from 84,000 (Nov. 23-29) to 70,000 (Nov. 30 to Dec. 6), for those aged 12-17 years. In that group, 61.6% have received at least one dose and 51.8% are fully vaccinated, the CDC said.

The pace of vaccinations varies for younger children as well, when geography is considered. The AAP analyzed the CDC’s data and found that 42% of all 5- to 11-year-olds in Vermont had received at least one dose as of Dec. 1, followed by Massachusetts (33%), Maine (30%), and Rhode Island (28%). At the other end of the vaccination scale are Alabama, Louisiana, Mississippi, and West Virginia, all with 4%, the AAP reported.

As the United States puts 7 million children infected with COVID-19 in its rear view mirror, another milestone is looming ahead: The CDC’s current count of deaths in children is 974.

rfranki@mdedge.com

Background: Recurrent cellulitis is a common condition in patients with lower-extremity edema. Although some clinicians recommend compression garments as a preventative treatment, there are no data evaluating their efficacy for this purpose.

Herscher_Michael_NY_2020_web.jpg

Dr. Herscher is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: Recurrent cellulitis is a common condition in patients with lower-extremity edema. Although some clinicians recommend compression garments as a preventative treatment, there are no data evaluating their efficacy for this purpose.

Herscher_Michael_NY_2020_web.jpg

Dr. Herscher is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.

Background: Recurrent cellulitis is a common condition in patients with lower-extremity edema. Although some clinicians recommend compression garments as a preventative treatment, there are no data evaluating their efficacy for this purpose.

Herscher_Michael_NY_2020_web.jpg

Dr. Herscher is a hospitalist in the Division of Hospital Medicine, Mount Sinai Health System, New York.