Perspectives in Hospital Medicine

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

In a few short months, the novel coronavirus SARS-CoV-2 has spread across the world, and illness caused by coronavirus 2019, or COVID-19, now affects every corner of the United States.¹ As healthcare systems prepare to care for a wave of affected patients, those with a teaching mission face the added challenge of balancing the educational needs and safety of trainees with those of delivering patient care. In response to concerns for student welfare, medical and nursing schools have suspended classroom-based education and clinical rotations.² The Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing (AACN) have emphasized the importance of adequate training in the use of personal protective equipment (PPE) for their trainees.³ The National League for Nursing has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotations because of safety concerns.⁴

These decisions have precedent: During the SARS-CoV epidemic in 2003, medical and nursing student education was temporarily halted in affected areas.^5-6 Healthcare trainees described concerns for their safety and reported adverse emotional impact.^7-9 In the current pandemic, there is variation in how countries around the world are approaching the role of learners, with options ranging from removing learners from the clinical environment to encouraging early graduation for students in hopes of ameliorating the impending physician shortage.^10-13 The need to balance educational goals with ethical concerns raised by this pandemic affects health professions trainees broadly.

Despite the challenges, there are unique educational opportunities at hand. In this Perspective, we draw on our collective experience, multiple informal interviews with educational leaders across the country, and educational literature to create a framework for health professions education during a crisis. From this framework, we propose a set of recommendations to assist educational policymakers and those working directly with learners to navigate these issues effectively.

Patient and Hospital Welfare

There are significant concerns about nosocomial spread of SARS-CoV-2. Having learners directly see COVID-19 patients can increase the risk of nosocomial spread. In one of the original case series, 29% of those infected were health care workers and 12.3% were patients hospitalized prior to infection.¹⁴ Additionally, preserving supplies of personal protective equipment (PPE) for healthcare workers has been a commonly cited reason for suspending student presence on clinical rotations. Insufficient supply of PPE has forced hospitals to relax PPE guidelines for those seeing patients under investigation and liberalize quarantine requirements for exposed health care workers, so many hospitals have reduced provider-patient interactions to only those considered essential.

Learner Welfare

As educators, we have a duty to keep our learners safe and psychologically well. The COVID-19 pandemic poses a risk of illness, permanent injury, or death among those infected. In some instances, the risks of exposure may be greater than the educational benefits of remaining in that clinical setting; however, health professions trainees at many institutions play such a central operational role that their absence could seriously impair overall care delivery. Furthermore, trainees are usually younger and healthier than supervising clinicians, which could leave them feeling an obligation to conduct a disproportionately large share of the direct patient contact. Despite these valid concerns, those being removed from the clinical environment for their safety could misinterpret it as a sign that their contributions or educational interests are not valued.

Educational Experience

Canceled clinical rotations will have significant negative educational effects on undergraduate learners. Depending on the extent of the pandemic’s effects, for example, third-year medical students may lack core rotations prior to applying for residency training. Other health professions face similar challenges—nursing students in their final year are likely missing their last opportunity for hands-on clinical training before graduation. Advanced practice nursing students may not be able to complete the required number of contact hours or clinical experiences mandated for accreditation. Graduate training programs must accommodate and adapt to these disparities when reviewing their applicant pools.

Absence from the clinical front lines, though, risks failing to capitalize on the unique educational opportunities presented by this pandemic. Students might miss the chance to learn about a new clinical entity and its increasingly varied clinical presentations, crisis medicine, infection control measures, emergency preparedness, ethics in the setting of scarce resources, public health and community response, communication in the setting of uncertainty and fear, and professionalism in the response to this singular situation. Trainees at all levels may miss the opportunity to stand alongside their teachers and peers to give care to those who need it most.

Heterogeneity of COVID-19 Responses Across the Country

The diversity of training sites in US health professions education has led to a wide range of responses to these challenges. In addition to regional variations, sites within individual academic programs are creating different educational and clinical polices, including the role of learners in the care of COVID-19 patients and even PPE requirements. Although educational accreditation bodies have offered guidance, implementation of creative responses has been left to individual schools, programs, and hospitals, creating important differences in learner training and experience.

Given these challenges, we offer four broad principles to guide health professions education in response to this pandemic. Within this framework, we offer multiple suggestions to individual educators, health professions programs, healthcare systems, and educational policymakers.

1. Prioritize healthcare system welfare: Patients are the core of our professional responsibility, and their needs take precedence. First and foremost, plans for our learners must always promote and support the proper functioning of the health system and its individual healthcare workers. To support care delivery, healthcare systems should do the following:

• Ensure educational activities minimize the risk of nosocomial transmission and adverse effects on patient safety. For example, hospitals can modify bedside care to reduce exposure by using phone or video for patient-trainee contact, performing selective physical examination only, and, when needed, prioritizing a single skilled examiner.
• Ensure learner use of PPE does not negatively affect availability for others, both now and as the pandemic unfolds.
• Engage learners in authentic, value-added healthcare activities outside of direct patient contact: tele-medicine, meeting with families, or spending video time with inpatients not under their direct care.

2. Promote learner welfare: Educators have a duty to ensure the physical and psychological safety of learners across the health professions continuum. By virtue of power differentials in the hierarchy of the teaching environment, learners can be particularly vulnerable. To promote learner wellbeing, educators should do the following:

• Deploy technology to maximize opportunities for and quality of non–face-to-face clinical, didactic, and interprofessional learning.
• Ensure learners have access to and proper training in the use of PPE, independent of whether they may be using PPE as part of clinical responsibilities, while remaining aware of the potential supply constraints during a pandemic.
• Deliberately include stop points during teaching for dialogue around fears, stress, resilience, and coping.¹⁵ Deploy additional resources for support, including in-person or virtual psychological and psychiatric care and crisis intervention counseling.
• Maintain flexibility regarding trainee’s educational needs. For example, welcome trainees from other services joining inpatient medicine or ICU teams. Acknowledge the stress they may feel and support them as they learn and adapt. This can be a unique opportunity for lessons in professionalism, teamwork, and communication.

3. Maximize educational value: Efforts must be made to preserve educational quality and content, limit educational cost, and leverage unique opportunities that may only be available during this time. Educators and programs should do the following:

• Adapt teaching to reflect changes in the hospital environment. A student may have spent more time on the phone with a patient; the nurse may have examined the patient; a resident may have vital sign and lab data; the attending may have spoken to the family or know about local policy changes affecting care. The usual modes of rounding should adapt, focusing on sharing and synthesizing multisource data to generate rapid, intelligent plans while mitigating risk.
• Turn the potential challenge of diminished access to previously routine diagnostic testing into an opportunity for trainees to assertively develop clinical skills often underutilized in practice environments without resource limitation.
• Discuss learning opportunities for healthcare ethics. Multiple aspects of this pandemic raise ethical issues around allocation of scarce resources and principles such as contingency and crisis standards of care: the availability and application of testing, potential changes to patient triage standards in which patients sicker than ever may be sent home, and crisis allocation of life support resources.
• Highlight opportunities to support interprofessional education and collaborative practice. As traditional professional boundaries are temporarily blurred, we may find nurses asking gowned physicians to perform nursing tasks (eg, inflate blood pressure cuffs). Physicians may ask nurses for patient-related information (eg, physical examination findings), all to limit collective risk, maximize efficiency, and minimize the use of scarce PPE.
• Teach telemedicine. This is an opportunity to create a cadre of clinicians adept with this type of practice for the future—even outside pandemics. Now may be the time for virtual visits to be better integrated into clinical practice, which has been of interest to patients and providers for some time, and to address the constraints of reimbursement policies.
• Provide explicit role modeling to ensure learners recognize and learn from the key components of faculty activity—modeling communication skills, engaging in clinical reasoning, or navigating clinical and professional uncertainty.¹⁶ For example, faculty could share their clinical reasoning regarding diagnosis of respiratory complaints. While COVID-19 may be the most urgent diagnostic consideration, educators can emphasize the risk and implications of anchoring bias as an important cause of diagnostic errors.
• Identify opportunities for educational scholarship around these and other changes resulting from the pandemic. Seek to engage learners in this work.

4. Communicate transparently: Learners must be witness to decision-making processes; this will demonstrate that their safety and education are valued. Wherever possible, include learners in decision-making discussions and in the process of disseminating information.

• At the institutional level, generate, modify, and share communication regarding the ways that education is changing and the values and goals behind those changes.
• Invite trainees as active contributors to intellectual exchanges regarding changes in the learning environment.
• Limit the negative impact of the “rumor mill” by replacing it with frequent, targeted, and accurate messaging that relies on evidence to the greatest extent possible.
• Strive for consistency in communication content but diversity in distribution to reach the learners in the most effective ways. In times of uncertainty and stress, err on the side of overcommunication.

Healthcare and medical education face a challenge unprecedented in our lifetimes. The COVID-19 pandemic will touch every aspect of how we care for patients, train the next generation of health professionals, and keep ourselves safe. By highlighting key issues facing health professions educators, offering a framework for education during pandemics, and providing specific suggestions for applying this framework, we hope to provide clarity on how we may advance our teaching mission and realize the educational opportunities as we face this crisis together.

The pandemic of coronavirus disease 2019 (COVID-19) is confronting the modern world like nothing else before. With over 20 million individuals expected to require hospitalization in the US, this health crisis may become a generation-defining moment for healthcare systems and the field of hospital medicine.¹ The specific challenges facing hospital medicine are comparable to running a sprint and a marathon—at the same time. For the sprint underway, hospitalists must learn to respond to a rapidly changing environment in which critical decisions are made within hours and days. At the same time, hospitalists need to plan for the marathon of increased clinical needs over the coming months, the possibility of burnout, and concerns about staff well-­being. Although runners typically focus on either the sprint or the marathon, healthcare systems and hospital medicine providers will need to simultaneously prepare for both types of races.

Over the past several weeks, hospital medicine leaders have been rapidly responding to an evolving crisis. Leaders and clinicians are quickly learning how to restructure clinical operations, negotiate the short supply of personal protective equipment (PPE), and manage delays in COVID-19 testing. In these areas, our hospitalist group has experienced a steep learning curve. In addition to the strategies outlined in the Table, we will share here our experiences and insights on managing and preparing for the COVID-19 pandemic.

Communication Is Central

During the sprint, focused, regular communication is imperative to ameliorate anxiety and fear. A study of crisis communication after 9/11 found that, for employees, good communication from leadership was one of the most valued factors.² Communications experts also note that, in times of crisis, leaders have a special role in communication, specifically around demystifying the situation, providing hope, and maintaining transparency.³

Mental bandwidth may be limited in a stressful environment, so efforts should be taken to maximize the value of each communication. Information on hospital metrics should be provided regularly, including the number of COVID-19 cases, the status of clinical services and staffing, hospital capacity, and resource availability.⁴ Although the ubiquity and ease of email is convenient, recognize that providers are likely receiving email updates from multiple layers within your healthcare organization. To guard against losing important information, we use the same templated format for daily email updates with changes highlighted, which allows busy clinicians to digest pertinent information easily.⁵ Finally, consider having a single individual be responsible for collating COVID-19–related emails sent to your group. Although clinicians may want to share the most recent studies or their clinical experiences with a group email, instead have them send this information to a single individual who can organize these materials and share them on a regular basis.

To keep two-way communication channels open in a busy, asynchronous environment, consider having a centralized shared document in which providers can give real-time feedback to capture on-the-ground experiences or share questions they would like answered. Within our group, we found that centralizing our conversation in a shared document eliminated redundancy, focused our meetings, and kept everyone up to date. Additionally, regularly scheduled meetings may need to be adapted to a remote format (eg, Zoom, WebEx) as clinicians are asked to work from home when not on clinical service. Finally, recognize that virtual meetings require a different skill set than that required by in-person meetings, including reestablishment of social norms and technology preparation.⁶

Optimize Your Staffing

Hospital volumes could increase to as high as 270% of current hospital bed capacities during this pandemic.¹ This surge is further complicated by the effort involved in caring for these patients, given their increased medical complexity, the use of new protocols, and the extra time needed to update staff and family. As the workload intensifies, staffing models and operations will also need to adapt.

First, optimize your inpatient resources based on the changes your hospital system is making. For instance, as elective surgeries were cancelled, we dissolved our surgical comanagement and consult services to better accommodate our hospitals’ needs. Further, consider using advanced practice providers (eg, physician assistants and nurse practitioners) released from their clinical duties to help with inpatient care in the event of a surge. If your hospital has trainees (eg, residents or fellows), consider reassigning those whose rotations have been postponed to newly created inpatient teams; trainees often have strong institutional knowledge and understanding of hospital protocols and resources.

Second, use hospitalists for their most relevant skills. Hospitalists are pluripotent clinicians who are comfortable with high-­acuity patients and can fit into a myriad of clinical positions. The initial instinct at our institution was to mobilize hospitalists across all areas of increasing needs in the hospital (eg, screening clinics,⁷ advice phone lines for patients, or in the Emergency Department), but we quickly recognized that the hospitalist group is a finite resource. We focused our hospitalists’ clinical work on the expanding inpatient needs and allowed other outpatient or procedure-based specialties that have less inpatient experience to fill the broader institutional gaps.

Finally, consider long-term implications of staffing decisions. Leaders are making challenging coverage decisions that can affect the morale and autonomy of staff. Does backup staffing happen on a volunteer basis? Who fills the need—those with less clinical time or those with fewer personal obligations? When a staffing model is challenged and your group is making such decisions, engaged communication again becomes paramount.

Experts believe that we are only at the beginning of this crisis, one for which we don’t know what the end looks like or when it will come. With this in mind, hospital medicine leadership must plan for the long-term implications of the lengthy race ahead. Recognizing that morale, motivation, and burnout will be issues to deal with on the horizon, a focus on sustainability and wellness will become increasingly important as the marathon continues. To date, we’ve found the following principles to be helpful.

Delegate Responsibilities

Hospitals will not be able to survive COVID-19 through the efforts of single individuals. Instead, consider creating “operational champion” roles for frontline clinicians. These individuals can lead in specific areas (eg, PPE, updates on COVID-19 testing, discharge protocols) and act as conduits for information, updates, and resources for your group. At our institution, such operational meetings and activities take hours out of each day. By creating a breadth of leadership roles, our group has spread the operational workload while still allowing clinicians to care for patients, avoid burnout, and build autonomy and opportunities for both personal and professional growth. While for most institutions, these positions are temporary and not compensated with salary or time, the contribution to the group should be recognized both now and in the future.

Focus on Wellness

Providers are battling a laundry list of both clinical and personal stressors. The Centers for Disease Control and Prevention has already recognized that stress and mental health are going to be large hurdles for both patients and providers during this crisis.⁸ From the beginning, hospitalist leadership should be attuned to physician wellness and be aware that burnout, mental and physical exhaustion, and the possibility of contracting COVID-19 will be issues in the coming weeks and months. Volunteerism is built into the physician’s work ethic, but we must be mindful about its cost for long-term staffing demands. In addition, scarce medical resources add an additional moral strain for clinicians as they face tough allocation decisions, as we’ve seen with our Italian colleagues.⁹

As regular meetings around COVID-19 have become commonplace, we’ve made sure to set aside defined time for staff to discuss and reflect on their experiences. Doing so has allowed our clinicians to feel heard and to acknowledge the difficulties they are facing in their clinical duties. Leaders should also consider frequent check-ins with individual providers. At our institution, the first positive COVID-19 patient did not radically change any protocol that was in place, but a check-in with the hospitalist on service that day proved helpful for a debrief and processing opportunity. Individual conversations can help those on the front lines feel supported and remind them they are not operating alone in an anonymous vacuum.

Continue by celebrating small victories because this marathon is not going to end with an obvious finish line or a singular moment in which everyone can rejoice. A negative test, a patient with a good outcome, and a donation of PPE are all opportunities to celebrate. It may be what keeps us going when there is no end in sight. We have relied on these celebrations and moments of levity as an integral part of our regular group meetings.

At the end of this pandemic, just as we hope that our social distancing feels like an overreaction, we similarly hope that our sprint to build capacity ends up being unnecessary as well. As we wrote this Perspectives piece, uncertainty about the extent, length, and impact of this pandemic still existed. By the time it is published it may be that the sprint is over, and the marathon is beginning. Or, if our wildest hopes come true, there will be no marathon to run at all.

The pandemic of coronavirus disease 2019 (COVID-19) is confronting the modern world like nothing else before. With over 20 million individuals expected to require hospitalization in the US, this health crisis may become a generation-defining moment for healthcare systems and the field of hospital medicine.¹ The specific challenges facing hospital medicine are comparable to running a sprint and a marathon—at the same time. For the sprint underway, hospitalists must learn to respond to a rapidly changing environment in which critical decisions are made within hours and days. At the same time, hospitalists need to plan for the marathon of increased clinical needs over the coming months, the possibility of burnout, and concerns about staff well-­being. Although runners typically focus on either the sprint or the marathon, healthcare systems and hospital medicine providers will need to simultaneously prepare for both types of races.

Over the past several weeks, hospital medicine leaders have been rapidly responding to an evolving crisis. Leaders and clinicians are quickly learning how to restructure clinical operations, negotiate the short supply of personal protective equipment (PPE), and manage delays in COVID-19 testing. In these areas, our hospitalist group has experienced a steep learning curve. In addition to the strategies outlined in the Table, we will share here our experiences and insights on managing and preparing for the COVID-19 pandemic.

Communication Is Central

During the sprint, focused, regular communication is imperative to ameliorate anxiety and fear. A study of crisis communication after 9/11 found that, for employees, good communication from leadership was one of the most valued factors.² Communications experts also note that, in times of crisis, leaders have a special role in communication, specifically around demystifying the situation, providing hope, and maintaining transparency.³

Mental bandwidth may be limited in a stressful environment, so efforts should be taken to maximize the value of each communication. Information on hospital metrics should be provided regularly, including the number of COVID-19 cases, the status of clinical services and staffing, hospital capacity, and resource availability.⁴ Although the ubiquity and ease of email is convenient, recognize that providers are likely receiving email updates from multiple layers within your healthcare organization. To guard against losing important information, we use the same templated format for daily email updates with changes highlighted, which allows busy clinicians to digest pertinent information easily.⁵ Finally, consider having a single individual be responsible for collating COVID-19–related emails sent to your group. Although clinicians may want to share the most recent studies or their clinical experiences with a group email, instead have them send this information to a single individual who can organize these materials and share them on a regular basis.

To keep two-way communication channels open in a busy, asynchronous environment, consider having a centralized shared document in which providers can give real-time feedback to capture on-the-ground experiences or share questions they would like answered. Within our group, we found that centralizing our conversation in a shared document eliminated redundancy, focused our meetings, and kept everyone up to date. Additionally, regularly scheduled meetings may need to be adapted to a remote format (eg, Zoom, WebEx) as clinicians are asked to work from home when not on clinical service. Finally, recognize that virtual meetings require a different skill set than that required by in-person meetings, including reestablishment of social norms and technology preparation.⁶

Optimize Your Staffing

Hospital volumes could increase to as high as 270% of current hospital bed capacities during this pandemic.¹ This surge is further complicated by the effort involved in caring for these patients, given their increased medical complexity, the use of new protocols, and the extra time needed to update staff and family. As the workload intensifies, staffing models and operations will also need to adapt.

First, optimize your inpatient resources based on the changes your hospital system is making. For instance, as elective surgeries were cancelled, we dissolved our surgical comanagement and consult services to better accommodate our hospitals’ needs. Further, consider using advanced practice providers (eg, physician assistants and nurse practitioners) released from their clinical duties to help with inpatient care in the event of a surge. If your hospital has trainees (eg, residents or fellows), consider reassigning those whose rotations have been postponed to newly created inpatient teams; trainees often have strong institutional knowledge and understanding of hospital protocols and resources.

Second, use hospitalists for their most relevant skills. Hospitalists are pluripotent clinicians who are comfortable with high-­acuity patients and can fit into a myriad of clinical positions. The initial instinct at our institution was to mobilize hospitalists across all areas of increasing needs in the hospital (eg, screening clinics,⁷ advice phone lines for patients, or in the Emergency Department), but we quickly recognized that the hospitalist group is a finite resource. We focused our hospitalists’ clinical work on the expanding inpatient needs and allowed other outpatient or procedure-based specialties that have less inpatient experience to fill the broader institutional gaps.

Finally, consider long-term implications of staffing decisions. Leaders are making challenging coverage decisions that can affect the morale and autonomy of staff. Does backup staffing happen on a volunteer basis? Who fills the need—those with less clinical time or those with fewer personal obligations? When a staffing model is challenged and your group is making such decisions, engaged communication again becomes paramount.

Experts believe that we are only at the beginning of this crisis, one for which we don’t know what the end looks like or when it will come. With this in mind, hospital medicine leadership must plan for the long-term implications of the lengthy race ahead. Recognizing that morale, motivation, and burnout will be issues to deal with on the horizon, a focus on sustainability and wellness will become increasingly important as the marathon continues. To date, we’ve found the following principles to be helpful.

Delegate Responsibilities

Hospitals will not be able to survive COVID-19 through the efforts of single individuals. Instead, consider creating “operational champion” roles for frontline clinicians. These individuals can lead in specific areas (eg, PPE, updates on COVID-19 testing, discharge protocols) and act as conduits for information, updates, and resources for your group. At our institution, such operational meetings and activities take hours out of each day. By creating a breadth of leadership roles, our group has spread the operational workload while still allowing clinicians to care for patients, avoid burnout, and build autonomy and opportunities for both personal and professional growth. While for most institutions, these positions are temporary and not compensated with salary or time, the contribution to the group should be recognized both now and in the future.

Focus on Wellness

Providers are battling a laundry list of both clinical and personal stressors. The Centers for Disease Control and Prevention has already recognized that stress and mental health are going to be large hurdles for both patients and providers during this crisis.⁸ From the beginning, hospitalist leadership should be attuned to physician wellness and be aware that burnout, mental and physical exhaustion, and the possibility of contracting COVID-19 will be issues in the coming weeks and months. Volunteerism is built into the physician’s work ethic, but we must be mindful about its cost for long-term staffing demands. In addition, scarce medical resources add an additional moral strain for clinicians as they face tough allocation decisions, as we’ve seen with our Italian colleagues.⁹

As regular meetings around COVID-19 have become commonplace, we’ve made sure to set aside defined time for staff to discuss and reflect on their experiences. Doing so has allowed our clinicians to feel heard and to acknowledge the difficulties they are facing in their clinical duties. Leaders should also consider frequent check-ins with individual providers. At our institution, the first positive COVID-19 patient did not radically change any protocol that was in place, but a check-in with the hospitalist on service that day proved helpful for a debrief and processing opportunity. Individual conversations can help those on the front lines feel supported and remind them they are not operating alone in an anonymous vacuum.

Continue by celebrating small victories because this marathon is not going to end with an obvious finish line or a singular moment in which everyone can rejoice. A negative test, a patient with a good outcome, and a donation of PPE are all opportunities to celebrate. It may be what keeps us going when there is no end in sight. We have relied on these celebrations and moments of levity as an integral part of our regular group meetings.

At the end of this pandemic, just as we hope that our social distancing feels like an overreaction, we similarly hope that our sprint to build capacity ends up being unnecessary as well. As we wrote this Perspectives piece, uncertainty about the extent, length, and impact of this pandemic still existed. By the time it is published it may be that the sprint is over, and the marathon is beginning. Or, if our wildest hopes come true, there will be no marathon to run at all.

The pandemic of coronavirus disease 2019 (COVID-19) is confronting the modern world like nothing else before. With over 20 million individuals expected to require hospitalization in the US, this health crisis may become a generation-defining moment for healthcare systems and the field of hospital medicine.¹ The specific challenges facing hospital medicine are comparable to running a sprint and a marathon—at the same time. For the sprint underway, hospitalists must learn to respond to a rapidly changing environment in which critical decisions are made within hours and days. At the same time, hospitalists need to plan for the marathon of increased clinical needs over the coming months, the possibility of burnout, and concerns about staff well-­being. Although runners typically focus on either the sprint or the marathon, healthcare systems and hospital medicine providers will need to simultaneously prepare for both types of races.

Over the past several weeks, hospital medicine leaders have been rapidly responding to an evolving crisis. Leaders and clinicians are quickly learning how to restructure clinical operations, negotiate the short supply of personal protective equipment (PPE), and manage delays in COVID-19 testing. In these areas, our hospitalist group has experienced a steep learning curve. In addition to the strategies outlined in the Table, we will share here our experiences and insights on managing and preparing for the COVID-19 pandemic.

Communication Is Central

During the sprint, focused, regular communication is imperative to ameliorate anxiety and fear. A study of crisis communication after 9/11 found that, for employees, good communication from leadership was one of the most valued factors.² Communications experts also note that, in times of crisis, leaders have a special role in communication, specifically around demystifying the situation, providing hope, and maintaining transparency.³

Mental bandwidth may be limited in a stressful environment, so efforts should be taken to maximize the value of each communication. Information on hospital metrics should be provided regularly, including the number of COVID-19 cases, the status of clinical services and staffing, hospital capacity, and resource availability.⁴ Although the ubiquity and ease of email is convenient, recognize that providers are likely receiving email updates from multiple layers within your healthcare organization. To guard against losing important information, we use the same templated format for daily email updates with changes highlighted, which allows busy clinicians to digest pertinent information easily.⁵ Finally, consider having a single individual be responsible for collating COVID-19–related emails sent to your group. Although clinicians may want to share the most recent studies or their clinical experiences with a group email, instead have them send this information to a single individual who can organize these materials and share them on a regular basis.

To keep two-way communication channels open in a busy, asynchronous environment, consider having a centralized shared document in which providers can give real-time feedback to capture on-the-ground experiences or share questions they would like answered. Within our group, we found that centralizing our conversation in a shared document eliminated redundancy, focused our meetings, and kept everyone up to date. Additionally, regularly scheduled meetings may need to be adapted to a remote format (eg, Zoom, WebEx) as clinicians are asked to work from home when not on clinical service. Finally, recognize that virtual meetings require a different skill set than that required by in-person meetings, including reestablishment of social norms and technology preparation.⁶

Optimize Your Staffing

Hospital volumes could increase to as high as 270% of current hospital bed capacities during this pandemic.¹ This surge is further complicated by the effort involved in caring for these patients, given their increased medical complexity, the use of new protocols, and the extra time needed to update staff and family. As the workload intensifies, staffing models and operations will also need to adapt.

First, optimize your inpatient resources based on the changes your hospital system is making. For instance, as elective surgeries were cancelled, we dissolved our surgical comanagement and consult services to better accommodate our hospitals’ needs. Further, consider using advanced practice providers (eg, physician assistants and nurse practitioners) released from their clinical duties to help with inpatient care in the event of a surge. If your hospital has trainees (eg, residents or fellows), consider reassigning those whose rotations have been postponed to newly created inpatient teams; trainees often have strong institutional knowledge and understanding of hospital protocols and resources.

Second, use hospitalists for their most relevant skills. Hospitalists are pluripotent clinicians who are comfortable with high-­acuity patients and can fit into a myriad of clinical positions. The initial instinct at our institution was to mobilize hospitalists across all areas of increasing needs in the hospital (eg, screening clinics,⁷ advice phone lines for patients, or in the Emergency Department), but we quickly recognized that the hospitalist group is a finite resource. We focused our hospitalists’ clinical work on the expanding inpatient needs and allowed other outpatient or procedure-based specialties that have less inpatient experience to fill the broader institutional gaps.

Finally, consider long-term implications of staffing decisions. Leaders are making challenging coverage decisions that can affect the morale and autonomy of staff. Does backup staffing happen on a volunteer basis? Who fills the need—those with less clinical time or those with fewer personal obligations? When a staffing model is challenged and your group is making such decisions, engaged communication again becomes paramount.

Experts believe that we are only at the beginning of this crisis, one for which we don’t know what the end looks like or when it will come. With this in mind, hospital medicine leadership must plan for the long-term implications of the lengthy race ahead. Recognizing that morale, motivation, and burnout will be issues to deal with on the horizon, a focus on sustainability and wellness will become increasingly important as the marathon continues. To date, we’ve found the following principles to be helpful.

Delegate Responsibilities

Hospitals will not be able to survive COVID-19 through the efforts of single individuals. Instead, consider creating “operational champion” roles for frontline clinicians. These individuals can lead in specific areas (eg, PPE, updates on COVID-19 testing, discharge protocols) and act as conduits for information, updates, and resources for your group. At our institution, such operational meetings and activities take hours out of each day. By creating a breadth of leadership roles, our group has spread the operational workload while still allowing clinicians to care for patients, avoid burnout, and build autonomy and opportunities for both personal and professional growth. While for most institutions, these positions are temporary and not compensated with salary or time, the contribution to the group should be recognized both now and in the future.

Focus on Wellness

Providers are battling a laundry list of both clinical and personal stressors. The Centers for Disease Control and Prevention has already recognized that stress and mental health are going to be large hurdles for both patients and providers during this crisis.⁸ From the beginning, hospitalist leadership should be attuned to physician wellness and be aware that burnout, mental and physical exhaustion, and the possibility of contracting COVID-19 will be issues in the coming weeks and months. Volunteerism is built into the physician’s work ethic, but we must be mindful about its cost for long-term staffing demands. In addition, scarce medical resources add an additional moral strain for clinicians as they face tough allocation decisions, as we’ve seen with our Italian colleagues.⁹

As regular meetings around COVID-19 have become commonplace, we’ve made sure to set aside defined time for staff to discuss and reflect on their experiences. Doing so has allowed our clinicians to feel heard and to acknowledge the difficulties they are facing in their clinical duties. Leaders should also consider frequent check-ins with individual providers. At our institution, the first positive COVID-19 patient did not radically change any protocol that was in place, but a check-in with the hospitalist on service that day proved helpful for a debrief and processing opportunity. Individual conversations can help those on the front lines feel supported and remind them they are not operating alone in an anonymous vacuum.

Continue by celebrating small victories because this marathon is not going to end with an obvious finish line or a singular moment in which everyone can rejoice. A negative test, a patient with a good outcome, and a donation of PPE are all opportunities to celebrate. It may be what keeps us going when there is no end in sight. We have relied on these celebrations and moments of levity as an integral part of our regular group meetings.

At the end of this pandemic, just as we hope that our social distancing feels like an overreaction, we similarly hope that our sprint to build capacity ends up being unnecessary as well. As we wrote this Perspectives piece, uncertainty about the extent, length, and impact of this pandemic still existed. By the time it is published it may be that the sprint is over, and the marathon is beginning. Or, if our wildest hopes come true, there will be no marathon to run at all.

Specialization, as detailed in Adam Smith’s 1776 landmark treatise, Wealth of Nations,¹ has been an enduring trend in labor and economics for centuries. Mirroring evolution in other sectors of the economy, the healthcare workforce has become ever more specialized.² General practitioners and family doctors have ceded ground to a bevy of specialists and subspecialists ranging from pediatric endocrinologists to otolaryngology-neurotologists. Given the growth in medical knowledge over the past century, this specialization seems both necessary and good. This same specialization that serves us in good times, though, leaves us woefully underprepared for an epidemic that will require large numbers of hospitalists/generalists and intensivists, such as the current coronavirus disease 2019 (COVID-19) pandemic.

A bit on terminology before we proceed. For purposes of this paper we define generalists as physicians trained in Internal Medicine, Family Medicine, Pediatrics, or Med/Peds who provide primary hospital care to adults and children. While some may argue that hospitalists are specialists in inpatient care, we would like to focus on hospitalists as generalists who focus on inpatient care and what we have in common with the broader community of generalists. We include as generalists anyone, irrespective of clinical training, who chooses broad primary patient responsibility over the narrower consultative role. There is always a specialist in our midst who knows more about a particular disease or condition; as generalists, most of us appreciate and welcome that expertise.

Sometimes it takes a pandemic like COVID-19 to highlight a tremendous blind spot in our healthcare system that, in retrospect, seems hard to have missed. What do we do when we need more generalists and have only a surplus of specialists, many of whom were involuntarily “furloughed” by canceled elective procedures and postponed clinics? How do we “un-specialize” our specialist workforce?

We will discuss some of the most pressing problems facing hospitals working to ensure adequate staffing for general inpatient units caused by the simultaneous reductions in physician availability (because of illness and/or quarantine) and markedly increased admissions of undifferentiated COVID-19–related illnesses. We will assume that hospitals have already activated all providers practicing in areas most similar to hospital medicine, including generalists who have mixed inpatient/outpatient practices, subspecialists with significant inpatient clinical roles, fellows, and advanced practice providers (APPs) with inpatient experience. The Accreditation Council for Graduate Medical Education released guidance around the roles of physician trainees during the pandemic.³ Despite these measures, though, further workforce augmentation will be vital. To that end, several challenges to clinical staffing are enumerated below, accompanied by strategies to address them.

1. Clinicians eager to help, but out of practice in the inpatient setting: As hospitals across the country work to develop physician staffing contingency plans for scenarios in which general inpatient volumes increase by 50%-300% while 33%-50% of hospitalists either become infected or require quarantine, many hospitals are looking to bolster their physician depth. We have been extremely gratified by the tremendous response from the broader physician communities in which we work. We have encountered retired physicians who have volunteered to come back to work despite being at higher risk of severe COVID-19 complications and physician-­scientists offering to step back into clinical roles. We have found outstanding subspecialists asking to work under the tutelage of experienced hospitalists; these specialists recognize how, despite years of clinical experience, they would need significant supervision to function in the inpatient setting. The humility and self-awareness of these volunteers has been phenomenal.

Retraining researchers, subspecialists, and retirees as hospitalists requires purposeful onboarding to target key educational goals. This onboarding should stress COVID-19–specific medical management, training in infection prevention and control, and hospital-specific workflow processes (eg, shift length, sign-over). Onboarding must also include access and orientation to electronic health records, training around inpatient documentation requirements, and billing practices. Non–COVID-19 healthcare will continue; hospitals and clinical leaders will need to determine whether certain specialists should focus on COVID-19 care alone and leave others to continue with speciality practice still needed. Ready access to hospital medicine and medical subspecialty consultation will be pivotal in supervising providers asked to step into hospitalist roles.

The onboarding process we describe might best be viewed through the lens of focused professional practice evaluation (FPPE). Required by the Joint Commission, FPPE is a process for the medical staff of a facility to evaluate privilege-specific competence by clinicians and is used for any new clinical privileges and when there may be question as to a current practitioner’s capabilities. The usual FPPE process includes reassessment of provider practice, typically at 3 to 6 months. Doing so may be challenging given overall workforce stress and the timing of clinical demand—eg, time for medical record review will be limited. Consideration of a “preceptorship” with an experienced hospitalist providing verbal oversight for providers with emergency privileges may be very appropriate. Indeed the Joint Commission recently published guidance around FPPE during the COVID-19 epidemic with the suggestion that mentorship and direct observation are reasonable ways to ensure quality.⁴

Concerns around scope of practice and medicolegal liability must be rapidly addressed by professional practice organizations, state medical boards, and medical malpractice insurers to protect frontline providers, nurses, and pharmacists. In particular, Joint Commission FPPE process requirements may need to be relaxed to respond to a surge in clinical demand. Contingency and crisis standards of care permit doing so. We welcome the introduction of processes to expedite provider licensure in many hard-hit states.

2. Clinicians who should not help because of medical comorbidities or age: Individuals with certain significant comorbidities (eg, inflammatory conditions treated with immunosuppressants, pulmonary disease, cancer with active treatment) or meeting certain age criteria should be discouraged from clinical work because the dangers of illness for them and of transmission of illness are high. Judgment and a version of mutual informed consent will be needed to address fewer clear scenarios, such as whether a 35-year-old physician who requires a steroid inhaler for asthma or a 64-year-old physician who is otherwise healthy have higher risk. It is our opinion that all physicians should contribute to the care of patients with documented or suspected COVID-19 unless they meet institutionally defined exclusion criteria. We should recognize that physicians who are unable to provide direct care to patients with COVID-19 infection may have significant remorse and feelings that they are letting down their colleagues and the oath they have taken. As the COVID -19 pandemic continues, we are quickly learning that physicians who have contraindications to providing care to patients with active COVID-19 infection can still contribute in numerous mission-critical ways. This may include virtual (telehealth) visits, preceptorship via telehealth of providers completing FPPE in hospital medicine practice, postdischarge follow-up of patients who are no longer infectious, and other care-­coordination activities, such as triaging direct admission calls.

3. Clinicians who should be able to help but are fearful: All efforts must be undertaken to protect healthcare workers from acquiring COVID-19. Nevertheless, there are models predicting that ultimately the vast majority of the world’s population will be exposed, including healthcare workers.^5,6 In our personal experience as hospitalists and leaders, the vast majority (95%-plus) of our hospitalists have not only continued to do their job but taken on additional responsibilities and clinical work despite the risk. We are hesitant to co-opt words like courage and bravery that we typically would reserve for people in far more hazardous lines of work than physicians, but in the current setting perhaps courage is the correct term. In quiet conversation, many are vaguely unnerved and some significantly so, but they set their angst aside and get to work. The same can be said for the numerous subspecialists, surgeons, nurses, and others who have volunteered to help.

Alternatively, as leaders, we must manage an extremely small minority of faculty who request to not care for patients with COVID-19 despite no clear contraindication. These situations are nuanced and fraught with difficulty for leaders. As physicians we have moral and ethical obligations to society.⁷ We also have contractual obligations to our employers. Finally, we have a professional duty to our colleagues. When such cases arise, as leaders we should try to understand the perspective of the physician making the request. It is also important to remember that as leaders we are obliged to be fair and equitable to all faculty; granting exceptions to some who ask to avoid COVID-19-related work, but not to others, is difficult to justify. Moreover, granting exceptions can undermine faith in leadership and inevitably sow discord. We suggest setting clear mutual expectations of engagement and not granting unwarranted exceptions.

In this time of a global pandemic, we face a looming shortage of hospital generalists, which calls for immediate and purposeful workforce expansion facilitated by learning to “un-specialize” certain providers. We propose utilizing the framework of FPPE to educate and support those joining hospital medicine teams. Hospitalists are innovators and health systems science leaders. Let’s draw on that strength now to rise to the challenge of COVID-19.

Specialization, as detailed in Adam Smith’s 1776 landmark treatise, Wealth of Nations,¹ has been an enduring trend in labor and economics for centuries. Mirroring evolution in other sectors of the economy, the healthcare workforce has become ever more specialized.² General practitioners and family doctors have ceded ground to a bevy of specialists and subspecialists ranging from pediatric endocrinologists to otolaryngology-neurotologists. Given the growth in medical knowledge over the past century, this specialization seems both necessary and good. This same specialization that serves us in good times, though, leaves us woefully underprepared for an epidemic that will require large numbers of hospitalists/generalists and intensivists, such as the current coronavirus disease 2019 (COVID-19) pandemic.

A bit on terminology before we proceed. For purposes of this paper we define generalists as physicians trained in Internal Medicine, Family Medicine, Pediatrics, or Med/Peds who provide primary hospital care to adults and children. While some may argue that hospitalists are specialists in inpatient care, we would like to focus on hospitalists as generalists who focus on inpatient care and what we have in common with the broader community of generalists. We include as generalists anyone, irrespective of clinical training, who chooses broad primary patient responsibility over the narrower consultative role. There is always a specialist in our midst who knows more about a particular disease or condition; as generalists, most of us appreciate and welcome that expertise.

Sometimes it takes a pandemic like COVID-19 to highlight a tremendous blind spot in our healthcare system that, in retrospect, seems hard to have missed. What do we do when we need more generalists and have only a surplus of specialists, many of whom were involuntarily “furloughed” by canceled elective procedures and postponed clinics? How do we “un-specialize” our specialist workforce?

We will discuss some of the most pressing problems facing hospitals working to ensure adequate staffing for general inpatient units caused by the simultaneous reductions in physician availability (because of illness and/or quarantine) and markedly increased admissions of undifferentiated COVID-19–related illnesses. We will assume that hospitals have already activated all providers practicing in areas most similar to hospital medicine, including generalists who have mixed inpatient/outpatient practices, subspecialists with significant inpatient clinical roles, fellows, and advanced practice providers (APPs) with inpatient experience. The Accreditation Council for Graduate Medical Education released guidance around the roles of physician trainees during the pandemic.³ Despite these measures, though, further workforce augmentation will be vital. To that end, several challenges to clinical staffing are enumerated below, accompanied by strategies to address them.

1. Clinicians eager to help, but out of practice in the inpatient setting: As hospitals across the country work to develop physician staffing contingency plans for scenarios in which general inpatient volumes increase by 50%-300% while 33%-50% of hospitalists either become infected or require quarantine, many hospitals are looking to bolster their physician depth. We have been extremely gratified by the tremendous response from the broader physician communities in which we work. We have encountered retired physicians who have volunteered to come back to work despite being at higher risk of severe COVID-19 complications and physician-­scientists offering to step back into clinical roles. We have found outstanding subspecialists asking to work under the tutelage of experienced hospitalists; these specialists recognize how, despite years of clinical experience, they would need significant supervision to function in the inpatient setting. The humility and self-awareness of these volunteers has been phenomenal.

Retraining researchers, subspecialists, and retirees as hospitalists requires purposeful onboarding to target key educational goals. This onboarding should stress COVID-19–specific medical management, training in infection prevention and control, and hospital-specific workflow processes (eg, shift length, sign-over). Onboarding must also include access and orientation to electronic health records, training around inpatient documentation requirements, and billing practices. Non–COVID-19 healthcare will continue; hospitals and clinical leaders will need to determine whether certain specialists should focus on COVID-19 care alone and leave others to continue with speciality practice still needed. Ready access to hospital medicine and medical subspecialty consultation will be pivotal in supervising providers asked to step into hospitalist roles.

The onboarding process we describe might best be viewed through the lens of focused professional practice evaluation (FPPE). Required by the Joint Commission, FPPE is a process for the medical staff of a facility to evaluate privilege-specific competence by clinicians and is used for any new clinical privileges and when there may be question as to a current practitioner’s capabilities. The usual FPPE process includes reassessment of provider practice, typically at 3 to 6 months. Doing so may be challenging given overall workforce stress and the timing of clinical demand—eg, time for medical record review will be limited. Consideration of a “preceptorship” with an experienced hospitalist providing verbal oversight for providers with emergency privileges may be very appropriate. Indeed the Joint Commission recently published guidance around FPPE during the COVID-19 epidemic with the suggestion that mentorship and direct observation are reasonable ways to ensure quality.⁴

Concerns around scope of practice and medicolegal liability must be rapidly addressed by professional practice organizations, state medical boards, and medical malpractice insurers to protect frontline providers, nurses, and pharmacists. In particular, Joint Commission FPPE process requirements may need to be relaxed to respond to a surge in clinical demand. Contingency and crisis standards of care permit doing so. We welcome the introduction of processes to expedite provider licensure in many hard-hit states.

2. Clinicians who should not help because of medical comorbidities or age: Individuals with certain significant comorbidities (eg, inflammatory conditions treated with immunosuppressants, pulmonary disease, cancer with active treatment) or meeting certain age criteria should be discouraged from clinical work because the dangers of illness for them and of transmission of illness are high. Judgment and a version of mutual informed consent will be needed to address fewer clear scenarios, such as whether a 35-year-old physician who requires a steroid inhaler for asthma or a 64-year-old physician who is otherwise healthy have higher risk. It is our opinion that all physicians should contribute to the care of patients with documented or suspected COVID-19 unless they meet institutionally defined exclusion criteria. We should recognize that physicians who are unable to provide direct care to patients with COVID-19 infection may have significant remorse and feelings that they are letting down their colleagues and the oath they have taken. As the COVID -19 pandemic continues, we are quickly learning that physicians who have contraindications to providing care to patients with active COVID-19 infection can still contribute in numerous mission-critical ways. This may include virtual (telehealth) visits, preceptorship via telehealth of providers completing FPPE in hospital medicine practice, postdischarge follow-up of patients who are no longer infectious, and other care-­coordination activities, such as triaging direct admission calls.

3. Clinicians who should be able to help but are fearful: All efforts must be undertaken to protect healthcare workers from acquiring COVID-19. Nevertheless, there are models predicting that ultimately the vast majority of the world’s population will be exposed, including healthcare workers.^5,6 In our personal experience as hospitalists and leaders, the vast majority (95%-plus) of our hospitalists have not only continued to do their job but taken on additional responsibilities and clinical work despite the risk. We are hesitant to co-opt words like courage and bravery that we typically would reserve for people in far more hazardous lines of work than physicians, but in the current setting perhaps courage is the correct term. In quiet conversation, many are vaguely unnerved and some significantly so, but they set their angst aside and get to work. The same can be said for the numerous subspecialists, surgeons, nurses, and others who have volunteered to help.

Alternatively, as leaders, we must manage an extremely small minority of faculty who request to not care for patients with COVID-19 despite no clear contraindication. These situations are nuanced and fraught with difficulty for leaders. As physicians we have moral and ethical obligations to society.⁷ We also have contractual obligations to our employers. Finally, we have a professional duty to our colleagues. When such cases arise, as leaders we should try to understand the perspective of the physician making the request. It is also important to remember that as leaders we are obliged to be fair and equitable to all faculty; granting exceptions to some who ask to avoid COVID-19-related work, but not to others, is difficult to justify. Moreover, granting exceptions can undermine faith in leadership and inevitably sow discord. We suggest setting clear mutual expectations of engagement and not granting unwarranted exceptions.

In this time of a global pandemic, we face a looming shortage of hospital generalists, which calls for immediate and purposeful workforce expansion facilitated by learning to “un-specialize” certain providers. We propose utilizing the framework of FPPE to educate and support those joining hospital medicine teams. Hospitalists are innovators and health systems science leaders. Let’s draw on that strength now to rise to the challenge of COVID-19.

Specialization, as detailed in Adam Smith’s 1776 landmark treatise, Wealth of Nations,¹ has been an enduring trend in labor and economics for centuries. Mirroring evolution in other sectors of the economy, the healthcare workforce has become ever more specialized.² General practitioners and family doctors have ceded ground to a bevy of specialists and subspecialists ranging from pediatric endocrinologists to otolaryngology-neurotologists. Given the growth in medical knowledge over the past century, this specialization seems both necessary and good. This same specialization that serves us in good times, though, leaves us woefully underprepared for an epidemic that will require large numbers of hospitalists/generalists and intensivists, such as the current coronavirus disease 2019 (COVID-19) pandemic.

A bit on terminology before we proceed. For purposes of this paper we define generalists as physicians trained in Internal Medicine, Family Medicine, Pediatrics, or Med/Peds who provide primary hospital care to adults and children. While some may argue that hospitalists are specialists in inpatient care, we would like to focus on hospitalists as generalists who focus on inpatient care and what we have in common with the broader community of generalists. We include as generalists anyone, irrespective of clinical training, who chooses broad primary patient responsibility over the narrower consultative role. There is always a specialist in our midst who knows more about a particular disease or condition; as generalists, most of us appreciate and welcome that expertise.

Sometimes it takes a pandemic like COVID-19 to highlight a tremendous blind spot in our healthcare system that, in retrospect, seems hard to have missed. What do we do when we need more generalists and have only a surplus of specialists, many of whom were involuntarily “furloughed” by canceled elective procedures and postponed clinics? How do we “un-specialize” our specialist workforce?

We will discuss some of the most pressing problems facing hospitals working to ensure adequate staffing for general inpatient units caused by the simultaneous reductions in physician availability (because of illness and/or quarantine) and markedly increased admissions of undifferentiated COVID-19–related illnesses. We will assume that hospitals have already activated all providers practicing in areas most similar to hospital medicine, including generalists who have mixed inpatient/outpatient practices, subspecialists with significant inpatient clinical roles, fellows, and advanced practice providers (APPs) with inpatient experience. The Accreditation Council for Graduate Medical Education released guidance around the roles of physician trainees during the pandemic.³ Despite these measures, though, further workforce augmentation will be vital. To that end, several challenges to clinical staffing are enumerated below, accompanied by strategies to address them.

1. Clinicians eager to help, but out of practice in the inpatient setting: As hospitals across the country work to develop physician staffing contingency plans for scenarios in which general inpatient volumes increase by 50%-300% while 33%-50% of hospitalists either become infected or require quarantine, many hospitals are looking to bolster their physician depth. We have been extremely gratified by the tremendous response from the broader physician communities in which we work. We have encountered retired physicians who have volunteered to come back to work despite being at higher risk of severe COVID-19 complications and physician-­scientists offering to step back into clinical roles. We have found outstanding subspecialists asking to work under the tutelage of experienced hospitalists; these specialists recognize how, despite years of clinical experience, they would need significant supervision to function in the inpatient setting. The humility and self-awareness of these volunteers has been phenomenal.

Retraining researchers, subspecialists, and retirees as hospitalists requires purposeful onboarding to target key educational goals. This onboarding should stress COVID-19–specific medical management, training in infection prevention and control, and hospital-specific workflow processes (eg, shift length, sign-over). Onboarding must also include access and orientation to electronic health records, training around inpatient documentation requirements, and billing practices. Non–COVID-19 healthcare will continue; hospitals and clinical leaders will need to determine whether certain specialists should focus on COVID-19 care alone and leave others to continue with speciality practice still needed. Ready access to hospital medicine and medical subspecialty consultation will be pivotal in supervising providers asked to step into hospitalist roles.

The onboarding process we describe might best be viewed through the lens of focused professional practice evaluation (FPPE). Required by the Joint Commission, FPPE is a process for the medical staff of a facility to evaluate privilege-specific competence by clinicians and is used for any new clinical privileges and when there may be question as to a current practitioner’s capabilities. The usual FPPE process includes reassessment of provider practice, typically at 3 to 6 months. Doing so may be challenging given overall workforce stress and the timing of clinical demand—eg, time for medical record review will be limited. Consideration of a “preceptorship” with an experienced hospitalist providing verbal oversight for providers with emergency privileges may be very appropriate. Indeed the Joint Commission recently published guidance around FPPE during the COVID-19 epidemic with the suggestion that mentorship and direct observation are reasonable ways to ensure quality.⁴

Concerns around scope of practice and medicolegal liability must be rapidly addressed by professional practice organizations, state medical boards, and medical malpractice insurers to protect frontline providers, nurses, and pharmacists. In particular, Joint Commission FPPE process requirements may need to be relaxed to respond to a surge in clinical demand. Contingency and crisis standards of care permit doing so. We welcome the introduction of processes to expedite provider licensure in many hard-hit states.

2. Clinicians who should not help because of medical comorbidities or age: Individuals with certain significant comorbidities (eg, inflammatory conditions treated with immunosuppressants, pulmonary disease, cancer with active treatment) or meeting certain age criteria should be discouraged from clinical work because the dangers of illness for them and of transmission of illness are high. Judgment and a version of mutual informed consent will be needed to address fewer clear scenarios, such as whether a 35-year-old physician who requires a steroid inhaler for asthma or a 64-year-old physician who is otherwise healthy have higher risk. It is our opinion that all physicians should contribute to the care of patients with documented or suspected COVID-19 unless they meet institutionally defined exclusion criteria. We should recognize that physicians who are unable to provide direct care to patients with COVID-19 infection may have significant remorse and feelings that they are letting down their colleagues and the oath they have taken. As the COVID -19 pandemic continues, we are quickly learning that physicians who have contraindications to providing care to patients with active COVID-19 infection can still contribute in numerous mission-critical ways. This may include virtual (telehealth) visits, preceptorship via telehealth of providers completing FPPE in hospital medicine practice, postdischarge follow-up of patients who are no longer infectious, and other care-­coordination activities, such as triaging direct admission calls.

3. Clinicians who should be able to help but are fearful: All efforts must be undertaken to protect healthcare workers from acquiring COVID-19. Nevertheless, there are models predicting that ultimately the vast majority of the world’s population will be exposed, including healthcare workers.^5,6 In our personal experience as hospitalists and leaders, the vast majority (95%-plus) of our hospitalists have not only continued to do their job but taken on additional responsibilities and clinical work despite the risk. We are hesitant to co-opt words like courage and bravery that we typically would reserve for people in far more hazardous lines of work than physicians, but in the current setting perhaps courage is the correct term. In quiet conversation, many are vaguely unnerved and some significantly so, but they set their angst aside and get to work. The same can be said for the numerous subspecialists, surgeons, nurses, and others who have volunteered to help.

Alternatively, as leaders, we must manage an extremely small minority of faculty who request to not care for patients with COVID-19 despite no clear contraindication. These situations are nuanced and fraught with difficulty for leaders. As physicians we have moral and ethical obligations to society.⁷ We also have contractual obligations to our employers. Finally, we have a professional duty to our colleagues. When such cases arise, as leaders we should try to understand the perspective of the physician making the request. It is also important to remember that as leaders we are obliged to be fair and equitable to all faculty; granting exceptions to some who ask to avoid COVID-19-related work, but not to others, is difficult to justify. Moreover, granting exceptions can undermine faith in leadership and inevitably sow discord. We suggest setting clear mutual expectations of engagement and not granting unwarranted exceptions.

In this time of a global pandemic, we face a looming shortage of hospital generalists, which calls for immediate and purposeful workforce expansion facilitated by learning to “un-specialize” certain providers. We propose utilizing the framework of FPPE to educate and support those joining hospital medicine teams. Hospitalists are innovators and health systems science leaders. Let’s draw on that strength now to rise to the challenge of COVID-19.

The current COVID-19 pandemic has raised substantial anxieties and fears for healthcare workers, many of which they have not previously encountered. Important ethical issues have arisen involving the tension between their duties to their patients and their duties to themselves and to their loved ones. While these fears and duties are not unique to physicians or to members of one specialty, this article will focus on hospitalists. In general, hospitalists have an obligation to care for patients even if this puts them at risk, but duties to patients may at times be constrained by duties to others. At the same time, hospitals have correlative obligations to protect their employees and mitigate risk. Balancing these duties requires weighing benefits and risks, often in the context of considerable uncertainty. At this current time, it is conceivable that the risks may become so great that caring for patients is no longer obligatory but becomes heroic.

Conflicting duties arise in a variety of ways. Hospitalists are at increased risk of contracting the virus, given workplace exposures. The risk of complications is even higher for those who are older or have chronic medical conditions. Further, the shortage of personal protective equipment (PPE) adds to the overall risk. Hospitalists may also have concerns about transmitting the virus to family members or friends, especially to those who are elderly or have comorbidities. Hospitalists may also become physically and emotionally exhausted as work and home demands increase. Concerns for the care of dependents adds to the stress as daycares and schools close and older relatives are isolated in their homes. Hospitalists who are single parents and those whose partners are also healthcare workers are especially affected. The duty to care, encumbered by the cumulative stressors, creates an environment ripe for conflict.

Hospitalists have a duty to expose themselves to some, albeit not unlimited, risks. There are different ways of characterizing this obligation.¹ Some base it in the knowledge and power differential between physicians and patients, a differential increased by patients’ illnesses. Others frame it as a social contract: physicians receive certain benefits and privileges and, in accepting them, incur certain duties. Physicians practicing in the 1980s may recall a similar discussion about treating patients with the human immunodeficiency virus (HIV), while those who practiced in other countries in the early 2000s faced a similar conflict during the severe acute respiratory syndrome (SARS) epidemic, caused by another coronavirus.² The expectation of accepting risk may have been weakened in the last several decades, however, by the relative lack of risk in treating hospitalized patients in the United States.

Hospitalists’ duties to themselves and to their families are both intrinsically and instrumentally important. Being a hospitalist is not every hospitalist’s sole or predominant identity. They may also be adult children, spouses, and/or parents, or school board members or leaders in religious communities. Each of these roles entails its own duties and fulfilling them is also important. Effectuating them may, however, be more difficult because of the pandemic. Adult children may feel obligated to shop for their parents and parents of young children may have more childcare obligations. If no one else can fulfill these duties, they might take precedence over professional duties.

By fulfilling their duties to themselves and others, hospitalists may also be enabled to serve their patients. Unlike some discrete events, such as mass shootings or tornados, for which contingency and crisis standards of care may last for hours or days, we may be working under altered standards of care for weeks or months. (A contingency standard of care involves doing things differently in order to produce comparable clinical outcomes. A crisis standard of care is reached when it’s no longer possible to produce comparable clinical outcomes and the focus shifts from individual patient’s best interests or preferences to trying to save the most lives.³) It, therefore, is important we maintain our health and well-being by getting adequate sleep, eating well, and exercising.⁴ Arranging alternative child- and eldercare may reduce distractions at work and decrease the chance of needing to leave work unexpectedly.

In addressing these ethical issues, one of the key considerations is reducing the risks. We can reduce some risks ourselves while maintaining comparable outcomes to our conventional practices. I hope that it would go without saying, for example, that we should not work when we are sick. It is also important that we engage in adequate physical distancing whenever possible. It is important that physical distancing measures be applied equitably to all employees and that the actions hospitalists take to reduce their exposure do not disproportionately burden trainees or other types of providers. Consider, for example, having residents or nurse practitioners examine patients instead of the attending physician. This places subordinates at greater risk. Attending physicians, however, may have the best examination skills and their feedback is integral to trainees’ learning. Modeling a commitment to the duty to care and equitably accepting risk is exceptionally important as team members and leaders.

We can check in with one another and support each other emotionally. If some colleagues have substantially higher risks of complications, they may be assigned alternative duties with lower exposure risks. As a relatively young specialty, this may be more feasible for hospitalists than other specialties with a greater number of older practitioners. Care, however, should be taken to respect individuals’ privacy and confidentiality.

Minimizing risk is also a responsibility of hospitals and the local, state, and federal government. They have crucial roles in, for example, establishing adequate infection control policies and securing sufficient PPE. Many institutions have already moved to contingency standards of care to conserve PPE.⁵ These efforts not only support the duty of reciprocity⁶ but also help maintain an adequate workforce by reducing sick leave. The government’s apparent failure to fulfill its obligation to stockpile and distribute adequate equipment is currently being acutely felt.⁷

There are other potential actions that facilities can take, such as providing scrubs, child- and eldercare, housing, or life insurance. Individuals may be concerned about infecting family members. There is unfortunately limited data about spread on objects or asymptomatic spread, but these are reasonable possibilities. Facilities can provide scrubs to employees who do not normally wear them to provide a further barrier between the facility and the employees’ homes. They can provide child and elder care. It has been wonderful to see local community organizations and groups of medical students provide childcare for healthcare workers and other essential employees.⁸ Healthcare facilities could also consider providing temporary housing to staff with family members at high risk of complications. During the Ebola outbreak, some facilities provided supplemental disability and life insurance to staff who volunteered to put themselves at risk to help assure that their families would be provided for if the staff member unfortunately contracted the virus and became disabled or died.

Reciprocal duties to healthcare workers in a crisis standard of care are unresolved. Establishing ethically and clinically sound ventilator triage criteria is complex.^9,10 Some argue that healthcare providers should have some degree of priority. One argument is that if they recover, they can return to work and save more lives. (Having individuals who have recovered and are theoretically immune treat patients without PPE is one proposed conservation strategy.) It is, however, unclear whether individuals are likely to recover in enough time to return to work while we are still in a crisis standard of care. A different argument is that healthcare workers should be given priority because they accepted risk. This assumes they were infected at work and not in the community. While this argument has merit, it could be influenced by or perceived to be influenced by self-interest. Prioritizing healthcare workers for scarce resources requires substantial community support.¹¹

While providers have a duty to accept some risks, this duty is not unlimited. The mitigation strategies may be unsuccessful, and the risks substantial. One can think of analogies in other fields. Firefighters, for example, expose themselves to risk to save lives and to protect property. They are trained to take calculated risks, considering the likelihood and type of benefit and the degree of risk, but not to be reckless. They will take greater risk to save a life than property, and less risk if the victim is unlikely to survive. Their obligation to accept risk is not unlimited. They may justifiably choose not to enter a building, which is at significant, imminent risk of collapse, to protect property. The same is true for physicians. They are obligated to expose themselves to some risk, but not at a high likelihood of serious injury or death. At some point the duty to care for patients becomes supererogatory; fulfilling the duty is no longer required but becomes optional and doing so is heroic.¹² Some facilities, for example, will not perform cardiopulmonary resuscitation under a crisis standard of care due to the high risk of exposure and the low likelihood of success.¹³

Weighing potential benefits and risk is difficult. This difficulty is exacerbated by uncertainty. Some decisions would be easier, for example, if there was better evidence regarding asymptomatic spread. Finally, the subjectivity of some of these decisions raises concerns about unconscious bias or self-interest. It is therefore valuable to make some decisions collectively rather than individually. In particular, it is important to include those with adequate situation awareness. Conversely, once decisions are made, it is valuable to communicate both the decision and its rationale, and to be open to revising them based on feedback.

Given the fear and uncertainty generated by the pandemic, some individuals may be tempted to act unethically. Individuals have, unfortunately, taken hospital supplies, such as masks and hand sanitizer, for household use, and healthcare providers have hoarded medications, such as hydroxychloroquine.¹⁴ Individuals may also be tempted to use PPE for encounters when it is not indicated. We should address these fears and anxieties in other ways, such as discussing them with colleagues, chaplains, social workers, or employee assistance programs. If you observe coworkers acting in a manner that appears to be unethical, it is important to address their behavior while still giving them the benefit of the doubt. If you do not receive a satisfactory response, you should utilize the appropriate chain of command.

Most hospitalists are encountering situations that they have not previously experienced in their careers. These situations generate significant fear and anxiety. Many of these situations involve tensions between our duties to our patients and our duties to ourselves and to our families and friends. This tension is heightened for individuals who are older or have chronic health conditions or have family members who are. While healthcare providers have an obligation to accept some risks, this duty is not unlimited. Hospitals, healthcare systems, and governments have reciprocal obligations to keep providers safe. It is important to think creatively about ways to minimize risk. Due to uncertainty and self-interest, it may be better to make decisions collectively and transparently.

The current COVID-19 pandemic has raised substantial anxieties and fears for healthcare workers, many of which they have not previously encountered. Important ethical issues have arisen involving the tension between their duties to their patients and their duties to themselves and to their loved ones. While these fears and duties are not unique to physicians or to members of one specialty, this article will focus on hospitalists. In general, hospitalists have an obligation to care for patients even if this puts them at risk, but duties to patients may at times be constrained by duties to others. At the same time, hospitals have correlative obligations to protect their employees and mitigate risk. Balancing these duties requires weighing benefits and risks, often in the context of considerable uncertainty. At this current time, it is conceivable that the risks may become so great that caring for patients is no longer obligatory but becomes heroic.

Conflicting duties arise in a variety of ways. Hospitalists are at increased risk of contracting the virus, given workplace exposures. The risk of complications is even higher for those who are older or have chronic medical conditions. Further, the shortage of personal protective equipment (PPE) adds to the overall risk. Hospitalists may also have concerns about transmitting the virus to family members or friends, especially to those who are elderly or have comorbidities. Hospitalists may also become physically and emotionally exhausted as work and home demands increase. Concerns for the care of dependents adds to the stress as daycares and schools close and older relatives are isolated in their homes. Hospitalists who are single parents and those whose partners are also healthcare workers are especially affected. The duty to care, encumbered by the cumulative stressors, creates an environment ripe for conflict.

Hospitalists have a duty to expose themselves to some, albeit not unlimited, risks. There are different ways of characterizing this obligation.¹ Some base it in the knowledge and power differential between physicians and patients, a differential increased by patients’ illnesses. Others frame it as a social contract: physicians receive certain benefits and privileges and, in accepting them, incur certain duties. Physicians practicing in the 1980s may recall a similar discussion about treating patients with the human immunodeficiency virus (HIV), while those who practiced in other countries in the early 2000s faced a similar conflict during the severe acute respiratory syndrome (SARS) epidemic, caused by another coronavirus.² The expectation of accepting risk may have been weakened in the last several decades, however, by the relative lack of risk in treating hospitalized patients in the United States.

Hospitalists’ duties to themselves and to their families are both intrinsically and instrumentally important. Being a hospitalist is not every hospitalist’s sole or predominant identity. They may also be adult children, spouses, and/or parents, or school board members or leaders in religious communities. Each of these roles entails its own duties and fulfilling them is also important. Effectuating them may, however, be more difficult because of the pandemic. Adult children may feel obligated to shop for their parents and parents of young children may have more childcare obligations. If no one else can fulfill these duties, they might take precedence over professional duties.

By fulfilling their duties to themselves and others, hospitalists may also be enabled to serve their patients. Unlike some discrete events, such as mass shootings or tornados, for which contingency and crisis standards of care may last for hours or days, we may be working under altered standards of care for weeks or months. (A contingency standard of care involves doing things differently in order to produce comparable clinical outcomes. A crisis standard of care is reached when it’s no longer possible to produce comparable clinical outcomes and the focus shifts from individual patient’s best interests or preferences to trying to save the most lives.³) It, therefore, is important we maintain our health and well-being by getting adequate sleep, eating well, and exercising.⁴ Arranging alternative child- and eldercare may reduce distractions at work and decrease the chance of needing to leave work unexpectedly.

In addressing these ethical issues, one of the key considerations is reducing the risks. We can reduce some risks ourselves while maintaining comparable outcomes to our conventional practices. I hope that it would go without saying, for example, that we should not work when we are sick. It is also important that we engage in adequate physical distancing whenever possible. It is important that physical distancing measures be applied equitably to all employees and that the actions hospitalists take to reduce their exposure do not disproportionately burden trainees or other types of providers. Consider, for example, having residents or nurse practitioners examine patients instead of the attending physician. This places subordinates at greater risk. Attending physicians, however, may have the best examination skills and their feedback is integral to trainees’ learning. Modeling a commitment to the duty to care and equitably accepting risk is exceptionally important as team members and leaders.

We can check in with one another and support each other emotionally. If some colleagues have substantially higher risks of complications, they may be assigned alternative duties with lower exposure risks. As a relatively young specialty, this may be more feasible for hospitalists than other specialties with a greater number of older practitioners. Care, however, should be taken to respect individuals’ privacy and confidentiality.

Minimizing risk is also a responsibility of hospitals and the local, state, and federal government. They have crucial roles in, for example, establishing adequate infection control policies and securing sufficient PPE. Many institutions have already moved to contingency standards of care to conserve PPE.⁵ These efforts not only support the duty of reciprocity⁶ but also help maintain an adequate workforce by reducing sick leave. The government’s apparent failure to fulfill its obligation to stockpile and distribute adequate equipment is currently being acutely felt.⁷

There are other potential actions that facilities can take, such as providing scrubs, child- and eldercare, housing, or life insurance. Individuals may be concerned about infecting family members. There is unfortunately limited data about spread on objects or asymptomatic spread, but these are reasonable possibilities. Facilities can provide scrubs to employees who do not normally wear them to provide a further barrier between the facility and the employees’ homes. They can provide child and elder care. It has been wonderful to see local community organizations and groups of medical students provide childcare for healthcare workers and other essential employees.⁸ Healthcare facilities could also consider providing temporary housing to staff with family members at high risk of complications. During the Ebola outbreak, some facilities provided supplemental disability and life insurance to staff who volunteered to put themselves at risk to help assure that their families would be provided for if the staff member unfortunately contracted the virus and became disabled or died.

Reciprocal duties to healthcare workers in a crisis standard of care are unresolved. Establishing ethically and clinically sound ventilator triage criteria is complex.^9,10 Some argue that healthcare providers should have some degree of priority. One argument is that if they recover, they can return to work and save more lives. (Having individuals who have recovered and are theoretically immune treat patients without PPE is one proposed conservation strategy.) It is, however, unclear whether individuals are likely to recover in enough time to return to work while we are still in a crisis standard of care. A different argument is that healthcare workers should be given priority because they accepted risk. This assumes they were infected at work and not in the community. While this argument has merit, it could be influenced by or perceived to be influenced by self-interest. Prioritizing healthcare workers for scarce resources requires substantial community support.¹¹

While providers have a duty to accept some risks, this duty is not unlimited. The mitigation strategies may be unsuccessful, and the risks substantial. One can think of analogies in other fields. Firefighters, for example, expose themselves to risk to save lives and to protect property. They are trained to take calculated risks, considering the likelihood and type of benefit and the degree of risk, but not to be reckless. They will take greater risk to save a life than property, and less risk if the victim is unlikely to survive. Their obligation to accept risk is not unlimited. They may justifiably choose not to enter a building, which is at significant, imminent risk of collapse, to protect property. The same is true for physicians. They are obligated to expose themselves to some risk, but not at a high likelihood of serious injury or death. At some point the duty to care for patients becomes supererogatory; fulfilling the duty is no longer required but becomes optional and doing so is heroic.¹² Some facilities, for example, will not perform cardiopulmonary resuscitation under a crisis standard of care due to the high risk of exposure and the low likelihood of success.¹³

Weighing potential benefits and risk is difficult. This difficulty is exacerbated by uncertainty. Some decisions would be easier, for example, if there was better evidence regarding asymptomatic spread. Finally, the subjectivity of some of these decisions raises concerns about unconscious bias or self-interest. It is therefore valuable to make some decisions collectively rather than individually. In particular, it is important to include those with adequate situation awareness. Conversely, once decisions are made, it is valuable to communicate both the decision and its rationale, and to be open to revising them based on feedback.

Given the fear and uncertainty generated by the pandemic, some individuals may be tempted to act unethically. Individuals have, unfortunately, taken hospital supplies, such as masks and hand sanitizer, for household use, and healthcare providers have hoarded medications, such as hydroxychloroquine.¹⁴ Individuals may also be tempted to use PPE for encounters when it is not indicated. We should address these fears and anxieties in other ways, such as discussing them with colleagues, chaplains, social workers, or employee assistance programs. If you observe coworkers acting in a manner that appears to be unethical, it is important to address their behavior while still giving them the benefit of the doubt. If you do not receive a satisfactory response, you should utilize the appropriate chain of command.

Most hospitalists are encountering situations that they have not previously experienced in their careers. These situations generate significant fear and anxiety. Many of these situations involve tensions between our duties to our patients and our duties to ourselves and to our families and friends. This tension is heightened for individuals who are older or have chronic health conditions or have family members who are. While healthcare providers have an obligation to accept some risks, this duty is not unlimited. Hospitals, healthcare systems, and governments have reciprocal obligations to keep providers safe. It is important to think creatively about ways to minimize risk. Due to uncertainty and self-interest, it may be better to make decisions collectively and transparently.

The current COVID-19 pandemic has raised substantial anxieties and fears for healthcare workers, many of which they have not previously encountered. Important ethical issues have arisen involving the tension between their duties to their patients and their duties to themselves and to their loved ones. While these fears and duties are not unique to physicians or to members of one specialty, this article will focus on hospitalists. In general, hospitalists have an obligation to care for patients even if this puts them at risk, but duties to patients may at times be constrained by duties to others. At the same time, hospitals have correlative obligations to protect their employees and mitigate risk. Balancing these duties requires weighing benefits and risks, often in the context of considerable uncertainty. At this current time, it is conceivable that the risks may become so great that caring for patients is no longer obligatory but becomes heroic.

Conflicting duties arise in a variety of ways. Hospitalists are at increased risk of contracting the virus, given workplace exposures. The risk of complications is even higher for those who are older or have chronic medical conditions. Further, the shortage of personal protective equipment (PPE) adds to the overall risk. Hospitalists may also have concerns about transmitting the virus to family members or friends, especially to those who are elderly or have comorbidities. Hospitalists may also become physically and emotionally exhausted as work and home demands increase. Concerns for the care of dependents adds to the stress as daycares and schools close and older relatives are isolated in their homes. Hospitalists who are single parents and those whose partners are also healthcare workers are especially affected. The duty to care, encumbered by the cumulative stressors, creates an environment ripe for conflict.

Hospitalists have a duty to expose themselves to some, albeit not unlimited, risks. There are different ways of characterizing this obligation.¹ Some base it in the knowledge and power differential between physicians and patients, a differential increased by patients’ illnesses. Others frame it as a social contract: physicians receive certain benefits and privileges and, in accepting them, incur certain duties. Physicians practicing in the 1980s may recall a similar discussion about treating patients with the human immunodeficiency virus (HIV), while those who practiced in other countries in the early 2000s faced a similar conflict during the severe acute respiratory syndrome (SARS) epidemic, caused by another coronavirus.² The expectation of accepting risk may have been weakened in the last several decades, however, by the relative lack of risk in treating hospitalized patients in the United States.

Hospitalists’ duties to themselves and to their families are both intrinsically and instrumentally important. Being a hospitalist is not every hospitalist’s sole or predominant identity. They may also be adult children, spouses, and/or parents, or school board members or leaders in religious communities. Each of these roles entails its own duties and fulfilling them is also important. Effectuating them may, however, be more difficult because of the pandemic. Adult children may feel obligated to shop for their parents and parents of young children may have more childcare obligations. If no one else can fulfill these duties, they might take precedence over professional duties.

By fulfilling their duties to themselves and others, hospitalists may also be enabled to serve their patients. Unlike some discrete events, such as mass shootings or tornados, for which contingency and crisis standards of care may last for hours or days, we may be working under altered standards of care for weeks or months. (A contingency standard of care involves doing things differently in order to produce comparable clinical outcomes. A crisis standard of care is reached when it’s no longer possible to produce comparable clinical outcomes and the focus shifts from individual patient’s best interests or preferences to trying to save the most lives.³) It, therefore, is important we maintain our health and well-being by getting adequate sleep, eating well, and exercising.⁴ Arranging alternative child- and eldercare may reduce distractions at work and decrease the chance of needing to leave work unexpectedly.

In addressing these ethical issues, one of the key considerations is reducing the risks. We can reduce some risks ourselves while maintaining comparable outcomes to our conventional practices. I hope that it would go without saying, for example, that we should not work when we are sick. It is also important that we engage in adequate physical distancing whenever possible. It is important that physical distancing measures be applied equitably to all employees and that the actions hospitalists take to reduce their exposure do not disproportionately burden trainees or other types of providers. Consider, for example, having residents or nurse practitioners examine patients instead of the attending physician. This places subordinates at greater risk. Attending physicians, however, may have the best examination skills and their feedback is integral to trainees’ learning. Modeling a commitment to the duty to care and equitably accepting risk is exceptionally important as team members and leaders.

We can check in with one another and support each other emotionally. If some colleagues have substantially higher risks of complications, they may be assigned alternative duties with lower exposure risks. As a relatively young specialty, this may be more feasible for hospitalists than other specialties with a greater number of older practitioners. Care, however, should be taken to respect individuals’ privacy and confidentiality.

Minimizing risk is also a responsibility of hospitals and the local, state, and federal government. They have crucial roles in, for example, establishing adequate infection control policies and securing sufficient PPE. Many institutions have already moved to contingency standards of care to conserve PPE.⁵ These efforts not only support the duty of reciprocity⁶ but also help maintain an adequate workforce by reducing sick leave. The government’s apparent failure to fulfill its obligation to stockpile and distribute adequate equipment is currently being acutely felt.⁷

There are other potential actions that facilities can take, such as providing scrubs, child- and eldercare, housing, or life insurance. Individuals may be concerned about infecting family members. There is unfortunately limited data about spread on objects or asymptomatic spread, but these are reasonable possibilities. Facilities can provide scrubs to employees who do not normally wear them to provide a further barrier between the facility and the employees’ homes. They can provide child and elder care. It has been wonderful to see local community organizations and groups of medical students provide childcare for healthcare workers and other essential employees.⁸ Healthcare facilities could also consider providing temporary housing to staff with family members at high risk of complications. During the Ebola outbreak, some facilities provided supplemental disability and life insurance to staff who volunteered to put themselves at risk to help assure that their families would be provided for if the staff member unfortunately contracted the virus and became disabled or died.

Reciprocal duties to healthcare workers in a crisis standard of care are unresolved. Establishing ethically and clinically sound ventilator triage criteria is complex.^9,10 Some argue that healthcare providers should have some degree of priority. One argument is that if they recover, they can return to work and save more lives. (Having individuals who have recovered and are theoretically immune treat patients without PPE is one proposed conservation strategy.) It is, however, unclear whether individuals are likely to recover in enough time to return to work while we are still in a crisis standard of care. A different argument is that healthcare workers should be given priority because they accepted risk. This assumes they were infected at work and not in the community. While this argument has merit, it could be influenced by or perceived to be influenced by self-interest. Prioritizing healthcare workers for scarce resources requires substantial community support.¹¹

While providers have a duty to accept some risks, this duty is not unlimited. The mitigation strategies may be unsuccessful, and the risks substantial. One can think of analogies in other fields. Firefighters, for example, expose themselves to risk to save lives and to protect property. They are trained to take calculated risks, considering the likelihood and type of benefit and the degree of risk, but not to be reckless. They will take greater risk to save a life than property, and less risk if the victim is unlikely to survive. Their obligation to accept risk is not unlimited. They may justifiably choose not to enter a building, which is at significant, imminent risk of collapse, to protect property. The same is true for physicians. They are obligated to expose themselves to some risk, but not at a high likelihood of serious injury or death. At some point the duty to care for patients becomes supererogatory; fulfilling the duty is no longer required but becomes optional and doing so is heroic.¹² Some facilities, for example, will not perform cardiopulmonary resuscitation under a crisis standard of care due to the high risk of exposure and the low likelihood of success.¹³

Weighing potential benefits and risk is difficult. This difficulty is exacerbated by uncertainty. Some decisions would be easier, for example, if there was better evidence regarding asymptomatic spread. Finally, the subjectivity of some of these decisions raises concerns about unconscious bias or self-interest. It is therefore valuable to make some decisions collectively rather than individually. In particular, it is important to include those with adequate situation awareness. Conversely, once decisions are made, it is valuable to communicate both the decision and its rationale, and to be open to revising them based on feedback.

Given the fear and uncertainty generated by the pandemic, some individuals may be tempted to act unethically. Individuals have, unfortunately, taken hospital supplies, such as masks and hand sanitizer, for household use, and healthcare providers have hoarded medications, such as hydroxychloroquine.¹⁴ Individuals may also be tempted to use PPE for encounters when it is not indicated. We should address these fears and anxieties in other ways, such as discussing them with colleagues, chaplains, social workers, or employee assistance programs. If you observe coworkers acting in a manner that appears to be unethical, it is important to address their behavior while still giving them the benefit of the doubt. If you do not receive a satisfactory response, you should utilize the appropriate chain of command.

Most hospitalists are encountering situations that they have not previously experienced in their careers. These situations generate significant fear and anxiety. Many of these situations involve tensions between our duties to our patients and our duties to ourselves and to our families and friends. This tension is heightened for individuals who are older or have chronic health conditions or have family members who are. While healthcare providers have an obligation to accept some risks, this duty is not unlimited. Hospitals, healthcare systems, and governments have reciprocal obligations to keep providers safe. It is important to think creatively about ways to minimize risk. Due to uncertainty and self-interest, it may be better to make decisions collectively and transparently.

A few days ago, I had a heartfelt conversation with my good friend Dr Omayra Mansfield. Dr Mansfield has been an Emergency Department Physician for more than 12 years. She is also the wife of another physician and the mother of two young children, the recently appointed Chief Medical Officer at a hospital at AdventHealth, and one of the first graduates of the Physician Leader Development Course I teach.

“During the leadership course, you always provided examples of how physicians are like soldiers,” she began. She reminded me of my words describing how both doctors and soldiers are part of a professional body, how both have a cherished ethos and a set of directing values to guide both their path and their actions as a very special part of our society, and how of all the professions in our society, the military and medicine are the only two that deal in life and death, albeit in very different ways.

She had certainly paid attention in our seminars. Now, as she and her team faced the COVID-19 pandemic, she realized their daily challenges are expanding and they are now going to war. The leadership discussions that had sparked so much debate in our colloquia had now become real.

Dr Mansfield explained that beyond caring for patients, one of her key concerns was the physical and emotional well-­being of the clinical staff at her hospital: the physicians, nurses, technicians, and clinicians under her care. Getting to her point, she asked if I might have any suggestions based on my time and experiences in combat that might be helpful to her as she “cared for her troops” as they faced the battle ahead.

Her request was a good one. Lessons from my military past immediately rushed to my mind. I started scribbling and came up with a Top Ten list of recommendations for anyone going into a tough fight. Here’s what I sent to her:

1. Find a battle-buddy. On the first day of Army basic training, drill sergeants pair new recruits with one another. That’s primarily for accountability purposes throughout the weeks of training—to ensure soldiers hold each other responsible for getting to the right place, at the right time, in the right uniform—but it’s also part of a larger psychological dynamic related to building teams and mutual support within organizations. Your battle-buddy is charged with keeping you out of trouble, having your back, and being there when you need it most. In combat, battle-buddies do all those things and then some; they protect you from harm in so many other ways. Healthcare providers during this crisis will sometimes feel all alone, and they need to rely on someone else to help them when times get really tough. Having a battle-buddy—for those at the healthcare team level, of course, but also among those at the level of clinical director, hospital administrator, CMO, or even CEO—will help get you through the tough times and provide sanity when you need it the most. So my first piece of advice: Find a battle-buddy.
2. Plan and prepare for things you don’t expect will happen. During a preparatory training exercise for our unit’s deployment to Iraq during the surge, when we thought the exercise was about to end, the trainers surprised us with a final crisis we had to solve. According to the scenario, Al Qaida had blown up a major bridge in our area, causing dire logistical problems for the security forces and challenges to the population as they brought their goods to market. I remember my initial reaction: “They don’t have the strength to do that. This’ll never happen,” I said to the Chief of Staff under my breath, as we started developing the required drill to counter the action and please the trainers. I quickly forgot about that lesson, until after we deployed. Two weeks into our 15-month tour in Iraq, the enemy blew the exact bridge that was part of the scenario, causing the exact problems that were predicted. Because we had prepared for the unexpected, we were able to quickly repair the bridge, reestablish the logistics flow, and satisfy the worried population. The lesson: Teams can hope for the best, but it’s always important to prepare for the worst—a lack of equipment, a key member of the team not being available to contribute, an overwhelming surge of patients—and then develop a plan to mitigate it. Take time to reflect, and ask yourself, What is the worst that can happen, what can the “enemy” do to disrupt our lives, and how do we prepare to counter it?
3. Get everyone into the fight. In every organizations, it’s often true that some people take on too much and try and do it all themselves, others do only what they’re told to do, there’s the unique few who want to contribute but don’t know how they can to help, and then there’s some who even attempt to avoid contributing at all. It’s important for leaders to know who on their team fits each of these categories. It’s even more critical for leaders to be able to find ways to relieve the overworked, assign tasks to those who might not know their role, bring those who want to contribute into the fold, and cross-train teams to help relieve those who are exhausted. Leaders must look across their “battlespace” and ensure everyone is contributing. Leaders assign everyone tasks and do their best to level—and lighten—the load of the overworked.
4. “Fatigue makes cowards of us all.” During any type of crisis, the body and mind will rapidly break down from lack of sleep, emotional strain, or overwhelming stress. While a 12-hour shift in a hospital is exceedingly tough even during normal operations, the COVID-19 crisis will demand dramatically more of all the members of any healthcare team. For that reason, leaders must incorporate rest cycles, team rotations, and half-days away from the hospitals even when all hands are on deck, as well as consider reducing shift times, if possible. Many who have experienced the disease in hot spots say this is really tough, but not attempting to plan for this will cause eventual breakdown and dysfunction. Take a break, do all you can to maintain a modicum of balance, and get away for a while.
5. Take time to huddle. Communication and information are always key, but especially critical during any crisis. One technique that has proven valuable, beyond meetings and shift changes, is a preshift and postshift huddle. Different from the formal passing of critical information, the huddle is a brief opportunity for teams to pass informal information, look each other in the eye, and perhaps even pray together. As a two-star general, I did that every morning in combat with my small team of sergeants, captains, and privates before we left the headquarters to visit units, and it gave us all the power of knowing we had shared information, and we had a common operating picture. It gave us strength. During a crisis, all kinds of communication, formal and informal, are key.
6. This ain’t peacetime. In a crisis, the enemy gets a vote. If leaders don’t find ways to counter the enemy’s action (and fast!), they’ll be behind the curve! It’s important to find the techniques and procedures that are bureaucratic (or even dumb) and overturn or eliminate them quickly. Decisions must be made with alacrity and with an understood flow, and people must be assigned responsibilities and held accountable to make things happen. In a crisis, speed in action will almost always trump perfection in understanding. Stay calm but ensure that those who might not understand this come around to the dynamics associated with the threat. A crisis isn’t the time for business as usual.
7. Force adaptation—don’t wait ’til things are over to adjust. In a crisis, faults and disconnects in techniques and procedures often bubble to the surface and cause consternation. Don’t wait for a break in the action to adjust and find new ways to do things because a break in the action will usually never happen. The military has an expression: “Those who adapt the fastest on the battlefield win.” Find ways to look for and then publicize your methods of adaptation to the team, pin the rose on someone to ensure the changes are made, and then have someone make a historical record so other teams might also learn from your scar tissue. Lessons from the fight must be incorporated by the organization, or they’re not “lessons learned.”
8. Talkin’ ain’t fightin’. During a crisis, it’s important to establish techniques of verbal shorthand between the members of a team, and everyone must know their responsibilities and required actions. In the military, this is called a battle drill; in medicine, you know it as a code. In these situations, leaders must find ways to pass information quickly, and the reaction should be immediate response. In a crisis, normal process must take on the dynamics of a “code.” All members of the team must understand that there are just times when things can’t be explained, but it’s also important that leaders know when to use this abbreviated format. Explain when you can, but act when you must.
9. Cherish your teams. Every single team will experience things that human beings aren’t designed or meant to handle—even those in the medical profession, who likely thought they had seen it all. There will be repeated and overwhelming trauma, with the expected emotional reactions. The approach during these situations requires empathy, humility, emotional understanding, and validation. Praise your team at every opportunity, find ways to turn mistakes into learning opportunities, but most importantly be human and find ways to provide memories that your team can cherish and look back upon. Give them memories.
10. Leaders don’t have the right to have a bad day. In 2004, after a 12-month deployment in Iraq, our unit was on our way home. We had been a long time away from our families, and we had experienced some tough fighting. A third of our unit had already returned to their families in Germany when we were told we would be extended because of a changing situation on the ground. A wave of frustration went through our 18,000 soldiers. Our commander then pulled us together, communicated our new mission, and told us he was also disappointed, but it was time we had to show our grit by getting those soldiers who had already returned to Europe back, unpack our equipment, and return to the fight. Then he said something I will always remember: “It’s tough, but understand your soldiers are looking at you to lead in this crisis … and leaders don’t have the right to have a bad day.” He didn’t mean we couldn’t be frustrated, or disappointed, or emotional, or even pissed off. He meant we just couldn’t show it when others were around. That’s one of the toughest things about leading during a crisis: The unimaginable is expected of leaders. And leaders have to be ready to lead.

All this advice may seem like philosophical musings rather than pragmatic thoughts for a crisis, but hopefully this advice will make a difference as healthcare providers tackle the issues ahead. Stay healthy, mitigate risks, but know that the calm provided by leaders will make a difference.

A few days ago, I had a heartfelt conversation with my good friend Dr Omayra Mansfield. Dr Mansfield has been an Emergency Department Physician for more than 12 years. She is also the wife of another physician and the mother of two young children, the recently appointed Chief Medical Officer at a hospital at AdventHealth, and one of the first graduates of the Physician Leader Development Course I teach.

“During the leadership course, you always provided examples of how physicians are like soldiers,” she began. She reminded me of my words describing how both doctors and soldiers are part of a professional body, how both have a cherished ethos and a set of directing values to guide both their path and their actions as a very special part of our society, and how of all the professions in our society, the military and medicine are the only two that deal in life and death, albeit in very different ways.

She had certainly paid attention in our seminars. Now, as she and her team faced the COVID-19 pandemic, she realized their daily challenges are expanding and they are now going to war. The leadership discussions that had sparked so much debate in our colloquia had now become real.

Dr Mansfield explained that beyond caring for patients, one of her key concerns was the physical and emotional well-­being of the clinical staff at her hospital: the physicians, nurses, technicians, and clinicians under her care. Getting to her point, she asked if I might have any suggestions based on my time and experiences in combat that might be helpful to her as she “cared for her troops” as they faced the battle ahead.

Her request was a good one. Lessons from my military past immediately rushed to my mind. I started scribbling and came up with a Top Ten list of recommendations for anyone going into a tough fight. Here’s what I sent to her:

1. Find a battle-buddy. On the first day of Army basic training, drill sergeants pair new recruits with one another. That’s primarily for accountability purposes throughout the weeks of training—to ensure soldiers hold each other responsible for getting to the right place, at the right time, in the right uniform—but it’s also part of a larger psychological dynamic related to building teams and mutual support within organizations. Your battle-buddy is charged with keeping you out of trouble, having your back, and being there when you need it most. In combat, battle-buddies do all those things and then some; they protect you from harm in so many other ways. Healthcare providers during this crisis will sometimes feel all alone, and they need to rely on someone else to help them when times get really tough. Having a battle-buddy—for those at the healthcare team level, of course, but also among those at the level of clinical director, hospital administrator, CMO, or even CEO—will help get you through the tough times and provide sanity when you need it the most. So my first piece of advice: Find a battle-buddy.
2. Plan and prepare for things you don’t expect will happen. During a preparatory training exercise for our unit’s deployment to Iraq during the surge, when we thought the exercise was about to end, the trainers surprised us with a final crisis we had to solve. According to the scenario, Al Qaida had blown up a major bridge in our area, causing dire logistical problems for the security forces and challenges to the population as they brought their goods to market. I remember my initial reaction: “They don’t have the strength to do that. This’ll never happen,” I said to the Chief of Staff under my breath, as we started developing the required drill to counter the action and please the trainers. I quickly forgot about that lesson, until after we deployed. Two weeks into our 15-month tour in Iraq, the enemy blew the exact bridge that was part of the scenario, causing the exact problems that were predicted. Because we had prepared for the unexpected, we were able to quickly repair the bridge, reestablish the logistics flow, and satisfy the worried population. The lesson: Teams can hope for the best, but it’s always important to prepare for the worst—a lack of equipment, a key member of the team not being available to contribute, an overwhelming surge of patients—and then develop a plan to mitigate it. Take time to reflect, and ask yourself, What is the worst that can happen, what can the “enemy” do to disrupt our lives, and how do we prepare to counter it?
3. Get everyone into the fight. In every organizations, it’s often true that some people take on too much and try and do it all themselves, others do only what they’re told to do, there’s the unique few who want to contribute but don’t know how they can to help, and then there’s some who even attempt to avoid contributing at all. It’s important for leaders to know who on their team fits each of these categories. It’s even more critical for leaders to be able to find ways to relieve the overworked, assign tasks to those who might not know their role, bring those who want to contribute into the fold, and cross-train teams to help relieve those who are exhausted. Leaders must look across their “battlespace” and ensure everyone is contributing. Leaders assign everyone tasks and do their best to level—and lighten—the load of the overworked.
4. “Fatigue makes cowards of us all.” During any type of crisis, the body and mind will rapidly break down from lack of sleep, emotional strain, or overwhelming stress. While a 12-hour shift in a hospital is exceedingly tough even during normal operations, the COVID-19 crisis will demand dramatically more of all the members of any healthcare team. For that reason, leaders must incorporate rest cycles, team rotations, and half-days away from the hospitals even when all hands are on deck, as well as consider reducing shift times, if possible. Many who have experienced the disease in hot spots say this is really tough, but not attempting to plan for this will cause eventual breakdown and dysfunction. Take a break, do all you can to maintain a modicum of balance, and get away for a while.
5. Take time to huddle. Communication and information are always key, but especially critical during any crisis. One technique that has proven valuable, beyond meetings and shift changes, is a preshift and postshift huddle. Different from the formal passing of critical information, the huddle is a brief opportunity for teams to pass informal information, look each other in the eye, and perhaps even pray together. As a two-star general, I did that every morning in combat with my small team of sergeants, captains, and privates before we left the headquarters to visit units, and it gave us all the power of knowing we had shared information, and we had a common operating picture. It gave us strength. During a crisis, all kinds of communication, formal and informal, are key.
6. This ain’t peacetime. In a crisis, the enemy gets a vote. If leaders don’t find ways to counter the enemy’s action (and fast!), they’ll be behind the curve! It’s important to find the techniques and procedures that are bureaucratic (or even dumb) and overturn or eliminate them quickly. Decisions must be made with alacrity and with an understood flow, and people must be assigned responsibilities and held accountable to make things happen. In a crisis, speed in action will almost always trump perfection in understanding. Stay calm but ensure that those who might not understand this come around to the dynamics associated with the threat. A crisis isn’t the time for business as usual.
7. Force adaptation—don’t wait ’til things are over to adjust. In a crisis, faults and disconnects in techniques and procedures often bubble to the surface and cause consternation. Don’t wait for a break in the action to adjust and find new ways to do things because a break in the action will usually never happen. The military has an expression: “Those who adapt the fastest on the battlefield win.” Find ways to look for and then publicize your methods of adaptation to the team, pin the rose on someone to ensure the changes are made, and then have someone make a historical record so other teams might also learn from your scar tissue. Lessons from the fight must be incorporated by the organization, or they’re not “lessons learned.”
8. Talkin’ ain’t fightin’. During a crisis, it’s important to establish techniques of verbal shorthand between the members of a team, and everyone must know their responsibilities and required actions. In the military, this is called a battle drill; in medicine, you know it as a code. In these situations, leaders must find ways to pass information quickly, and the reaction should be immediate response. In a crisis, normal process must take on the dynamics of a “code.” All members of the team must understand that there are just times when things can’t be explained, but it’s also important that leaders know when to use this abbreviated format. Explain when you can, but act when you must.
9. Cherish your teams. Every single team will experience things that human beings aren’t designed or meant to handle—even those in the medical profession, who likely thought they had seen it all. There will be repeated and overwhelming trauma, with the expected emotional reactions. The approach during these situations requires empathy, humility, emotional understanding, and validation. Praise your team at every opportunity, find ways to turn mistakes into learning opportunities, but most importantly be human and find ways to provide memories that your team can cherish and look back upon. Give them memories.
10. Leaders don’t have the right to have a bad day. In 2004, after a 12-month deployment in Iraq, our unit was on our way home. We had been a long time away from our families, and we had experienced some tough fighting. A third of our unit had already returned to their families in Germany when we were told we would be extended because of a changing situation on the ground. A wave of frustration went through our 18,000 soldiers. Our commander then pulled us together, communicated our new mission, and told us he was also disappointed, but it was time we had to show our grit by getting those soldiers who had already returned to Europe back, unpack our equipment, and return to the fight. Then he said something I will always remember: “It’s tough, but understand your soldiers are looking at you to lead in this crisis … and leaders don’t have the right to have a bad day.” He didn’t mean we couldn’t be frustrated, or disappointed, or emotional, or even pissed off. He meant we just couldn’t show it when others were around. That’s one of the toughest things about leading during a crisis: The unimaginable is expected of leaders. And leaders have to be ready to lead.

All this advice may seem like philosophical musings rather than pragmatic thoughts for a crisis, but hopefully this advice will make a difference as healthcare providers tackle the issues ahead. Stay healthy, mitigate risks, but know that the calm provided by leaders will make a difference.

A few days ago, I had a heartfelt conversation with my good friend Dr Omayra Mansfield. Dr Mansfield has been an Emergency Department Physician for more than 12 years. She is also the wife of another physician and the mother of two young children, the recently appointed Chief Medical Officer at a hospital at AdventHealth, and one of the first graduates of the Physician Leader Development Course I teach.

“During the leadership course, you always provided examples of how physicians are like soldiers,” she began. She reminded me of my words describing how both doctors and soldiers are part of a professional body, how both have a cherished ethos and a set of directing values to guide both their path and their actions as a very special part of our society, and how of all the professions in our society, the military and medicine are the only two that deal in life and death, albeit in very different ways.

She had certainly paid attention in our seminars. Now, as she and her team faced the COVID-19 pandemic, she realized their daily challenges are expanding and they are now going to war. The leadership discussions that had sparked so much debate in our colloquia had now become real.

Dr Mansfield explained that beyond caring for patients, one of her key concerns was the physical and emotional well-­being of the clinical staff at her hospital: the physicians, nurses, technicians, and clinicians under her care. Getting to her point, she asked if I might have any suggestions based on my time and experiences in combat that might be helpful to her as she “cared for her troops” as they faced the battle ahead.

Her request was a good one. Lessons from my military past immediately rushed to my mind. I started scribbling and came up with a Top Ten list of recommendations for anyone going into a tough fight. Here’s what I sent to her:

1. Find a battle-buddy. On the first day of Army basic training, drill sergeants pair new recruits with one another. That’s primarily for accountability purposes throughout the weeks of training—to ensure soldiers hold each other responsible for getting to the right place, at the right time, in the right uniform—but it’s also part of a larger psychological dynamic related to building teams and mutual support within organizations. Your battle-buddy is charged with keeping you out of trouble, having your back, and being there when you need it most. In combat, battle-buddies do all those things and then some; they protect you from harm in so many other ways. Healthcare providers during this crisis will sometimes feel all alone, and they need to rely on someone else to help them when times get really tough. Having a battle-buddy—for those at the healthcare team level, of course, but also among those at the level of clinical director, hospital administrator, CMO, or even CEO—will help get you through the tough times and provide sanity when you need it the most. So my first piece of advice: Find a battle-buddy.
2. Plan and prepare for things you don’t expect will happen. During a preparatory training exercise for our unit’s deployment to Iraq during the surge, when we thought the exercise was about to end, the trainers surprised us with a final crisis we had to solve. According to the scenario, Al Qaida had blown up a major bridge in our area, causing dire logistical problems for the security forces and challenges to the population as they brought their goods to market. I remember my initial reaction: “They don’t have the strength to do that. This’ll never happen,” I said to the Chief of Staff under my breath, as we started developing the required drill to counter the action and please the trainers. I quickly forgot about that lesson, until after we deployed. Two weeks into our 15-month tour in Iraq, the enemy blew the exact bridge that was part of the scenario, causing the exact problems that were predicted. Because we had prepared for the unexpected, we were able to quickly repair the bridge, reestablish the logistics flow, and satisfy the worried population. The lesson: Teams can hope for the best, but it’s always important to prepare for the worst—a lack of equipment, a key member of the team not being available to contribute, an overwhelming surge of patients—and then develop a plan to mitigate it. Take time to reflect, and ask yourself, What is the worst that can happen, what can the “enemy” do to disrupt our lives, and how do we prepare to counter it?
3. Get everyone into the fight. In every organizations, it’s often true that some people take on too much and try and do it all themselves, others do only what they’re told to do, there’s the unique few who want to contribute but don’t know how they can to help, and then there’s some who even attempt to avoid contributing at all. It’s important for leaders to know who on their team fits each of these categories. It’s even more critical for leaders to be able to find ways to relieve the overworked, assign tasks to those who might not know their role, bring those who want to contribute into the fold, and cross-train teams to help relieve those who are exhausted. Leaders must look across their “battlespace” and ensure everyone is contributing. Leaders assign everyone tasks and do their best to level—and lighten—the load of the overworked.
4. “Fatigue makes cowards of us all.” During any type of crisis, the body and mind will rapidly break down from lack of sleep, emotional strain, or overwhelming stress. While a 12-hour shift in a hospital is exceedingly tough even during normal operations, the COVID-19 crisis will demand dramatically more of all the members of any healthcare team. For that reason, leaders must incorporate rest cycles, team rotations, and half-days away from the hospitals even when all hands are on deck, as well as consider reducing shift times, if possible. Many who have experienced the disease in hot spots say this is really tough, but not attempting to plan for this will cause eventual breakdown and dysfunction. Take a break, do all you can to maintain a modicum of balance, and get away for a while.
5. Take time to huddle. Communication and information are always key, but especially critical during any crisis. One technique that has proven valuable, beyond meetings and shift changes, is a preshift and postshift huddle. Different from the formal passing of critical information, the huddle is a brief opportunity for teams to pass informal information, look each other in the eye, and perhaps even pray together. As a two-star general, I did that every morning in combat with my small team of sergeants, captains, and privates before we left the headquarters to visit units, and it gave us all the power of knowing we had shared information, and we had a common operating picture. It gave us strength. During a crisis, all kinds of communication, formal and informal, are key.
6. This ain’t peacetime. In a crisis, the enemy gets a vote. If leaders don’t find ways to counter the enemy’s action (and fast!), they’ll be behind the curve! It’s important to find the techniques and procedures that are bureaucratic (or even dumb) and overturn or eliminate them quickly. Decisions must be made with alacrity and with an understood flow, and people must be assigned responsibilities and held accountable to make things happen. In a crisis, speed in action will almost always trump perfection in understanding. Stay calm but ensure that those who might not understand this come around to the dynamics associated with the threat. A crisis isn’t the time for business as usual.
7. Force adaptation—don’t wait ’til things are over to adjust. In a crisis, faults and disconnects in techniques and procedures often bubble to the surface and cause consternation. Don’t wait for a break in the action to adjust and find new ways to do things because a break in the action will usually never happen. The military has an expression: “Those who adapt the fastest on the battlefield win.” Find ways to look for and then publicize your methods of adaptation to the team, pin the rose on someone to ensure the changes are made, and then have someone make a historical record so other teams might also learn from your scar tissue. Lessons from the fight must be incorporated by the organization, or they’re not “lessons learned.”
8. Talkin’ ain’t fightin’. During a crisis, it’s important to establish techniques of verbal shorthand between the members of a team, and everyone must know their responsibilities and required actions. In the military, this is called a battle drill; in medicine, you know it as a code. In these situations, leaders must find ways to pass information quickly, and the reaction should be immediate response. In a crisis, normal process must take on the dynamics of a “code.” All members of the team must understand that there are just times when things can’t be explained, but it’s also important that leaders know when to use this abbreviated format. Explain when you can, but act when you must.
9. Cherish your teams. Every single team will experience things that human beings aren’t designed or meant to handle—even those in the medical profession, who likely thought they had seen it all. There will be repeated and overwhelming trauma, with the expected emotional reactions. The approach during these situations requires empathy, humility, emotional understanding, and validation. Praise your team at every opportunity, find ways to turn mistakes into learning opportunities, but most importantly be human and find ways to provide memories that your team can cherish and look back upon. Give them memories.
10. Leaders don’t have the right to have a bad day. In 2004, after a 12-month deployment in Iraq, our unit was on our way home. We had been a long time away from our families, and we had experienced some tough fighting. A third of our unit had already returned to their families in Germany when we were told we would be extended because of a changing situation on the ground. A wave of frustration went through our 18,000 soldiers. Our commander then pulled us together, communicated our new mission, and told us he was also disappointed, but it was time we had to show our grit by getting those soldiers who had already returned to Europe back, unpack our equipment, and return to the fight. Then he said something I will always remember: “It’s tough, but understand your soldiers are looking at you to lead in this crisis … and leaders don’t have the right to have a bad day.” He didn’t mean we couldn’t be frustrated, or disappointed, or emotional, or even pissed off. He meant we just couldn’t show it when others were around. That’s one of the toughest things about leading during a crisis: The unimaginable is expected of leaders. And leaders have to be ready to lead.

All this advice may seem like philosophical musings rather than pragmatic thoughts for a crisis, but hopefully this advice will make a difference as healthcare providers tackle the issues ahead. Stay healthy, mitigate risks, but know that the calm provided by leaders will make a difference.

The field of telemedicine, in which clinicians use remote evaluation and monitoring to diagnose and treat patients, has grown substantially over the past decade. Its roles in acute care medicine settings are diverse, including virtual intensive care unit (ICU) care, after-­hours medical admissions, cross coverage, and, most aptly, disaster management.¹

At HealthPartners, a large integrated healthcare delivery and financing system based in the Twin Cities region of Minnesota, we have used provider-initiated telemedicine in hospital medicine for more than 2 years, providing evening and nighttime hospitalist coverage to our rural hospitals. We additionally provide a 24/7 nurse practitioner-staffed virtual clinic called Virtuwell.² Because we are now immersed in a global pandemic, we have taken steps to bolster our telemedicine infrastructure to meet increasing needs.

SARS-CoV-2, the causative agent of COVID-19, is a novel coronavirus with the capability to cause severe illness in roughly 14% of those infected.³ According to some estimates, the virus may infect up to 60% of the US population in the next year.⁴ As the pandemic looms over the country and the healthcare community, telemedicine can offer tools to help respond to this crisis. Healthcare systems leveraging telemedicine for patient care will gain several advantages, including workforce sustainability, reduction of provider burnout, limitation of provider exposure, and reduction of personal protective equipment (PPE) waste (Table). Telemedicine can also facilitate staffing of both large and small facilities that find themselves overwhelmed with pandemic-related patient overload (PRPO). Although telemedicine holds promise for pandemic response, this technology has limitations. It requires robust IT infrastructure, training of both nurses and physicians, and modifications to integrate within hospital workflows. In this article, we summarize key clinical needs that telemedicine can meet, implementation challenges, and important business considerations.

Our organization currently uses telemedicine to provide after-­hours hospital medicine coverage from 6 pm to 8 am at five rural and critical-access hospitals. We utilize commercial telemedicine carts on-site at hospitals and company-provided laptops at home. Our video visits are completed using enterprise video software and commercial digital stethoscopes. In the past month, we have increased our capacity, including at two large tertiary-care hospitals, by adding web cameras to existing mobile workstations and purchasing additional laptops for new telemedicine providers. Major barriers we encountered included cost, credentialing providers across multiple sites, and equipment testing. However, with close coordination with executive leadership, use of disaster credentialing, and robust IT support, we have been able to move past these obstacles in expanding our telemedicine infrastructure for support during this crucial time.

Patient Triage

Limiting exposure in the community and in the acute care setting is key to “flattening the curve” in pandemics.⁵ Triaging patients by telephone and online surveys is an important method to prevent high-risk patients from exposing others to infection. For example, since March 9, 2020, over 20,000 patients have called in weekly for COVID-19 screening. Although our organization introduced drive-up testing to reduce exposure, patients are still presenting to our clinics and emergency rooms in need of screening and testing. In several of our clinics, patients have been roomed alone to facilitate screening in the room by use of Google Duo, a free video chat product. Rooms with telemedicine capabilities allow patients with potentially communicable infections to be evaluated and observed while avoiding the risk of viral transmission. Additional considerations could include self-administered nasal swabs; although this has comparable efficacy to staff-administered swabs,⁶ it has not yet been implemented in our clinics.

Direct Care

Virtual care, specifically synchronous video and audio provider-­initiated services, is a well-established modality to provide direct care to patients in acute care and ambulatory settings.⁷ Telemedicine can be deployed to care for hospitalized patients in most locations as long as they meet the operational requirements described below. With a bedside nurse or other facilitator, patients can be interviewed and examined using a high definition camera and digital peripherals, including stethoscopes, otoscopes, ophthalmoscopes, and dermatoscopes. COVID-19 patients or patients under investigation may be seen in this manner. In-person visits should remain part of patients’ care as an important part of the provider-patient relationship⁸; however, telemedicine could still be deployed to provide direct care and monitoring to these patients while minimizing exposure to healthcare personnel. Additionally, telemedicine can be used for specialist consultations that are likely in high demand with COVID-19, including infectious disease, cardiology, and pulmonology.

Exposure Reduction and Resource Allocation

Currently in the United States there are concerns for shortages of PPE including surgical masks and N95 respirators. Telemedicine can reduce provider exposure, increase provider efficiency, and curtail PPE utilization by minimizing the number and frequency of in-room visits while still allowing virtual visits for direct patient care. For instance, our nursing staff is currently using telemedicine to conduct hourly rounding and limit unnecessary in-room visits.

We recommend keeping telemedicine equipment within individual isolation rooms intended for COVID-19 patients in order to eliminate the need for repeated cleaning. For other patients, a mobile cart could be used. Most commercial video software can autoanswer calls to allow for staff-free history taking. For a thorough physical exam, a bedside facilitator is need for use of digital stethoscopes and similar peripherals.

Provider Shortages and Reducing Burnout

Because SARS-CoV-2 is a highly contagious pathogen that can spread prior to symptom presentation, current CDC guidelines recommend self-monitoring at home for health care workers who have a healthcare-related exposure to a COVID-19 patient.⁹ This can leave significant gaps in coverage for healthcare systems. For example, in Vacaville, California, one positive case resulted in over 200 health care workers unable to work on site.¹⁰

Large volumes of acutely ill patients, coupled with the risk of ill or quarantined providers, means provider shortages due to PRPO are likely to occur and threaten hospitals’ ability to care for patients with or without COVID-19. Furthermore, given increased patient loads, frontline staff are at exceptionally high risk of burnout in pandemic situations. Hospital medicine teams will need contingency plans to meet the needs. Using telemedicine to protect the workforce and maintain staffing levels will reduce that risk.

Telehospitalists can see and examine patients, write orders, and maintain patient service lines much like in-person providers. Recently, we have used it when providers are ill or self-monitoring. In multisite systems, telehospitalists who are privileged in multiple hospitals can be efficiently deployed to meet patient care needs and relieve overburdened providers across hundreds of miles or more.

Enabling patient rooms for telemedicine allows telehospitalists and other providers to see hospitalized patients. Furthermore, quarantined hospitalists can continue to work and support in-person clinical services during PRPO. Providers in high-risk groups (eg, older, immunosuppressed, pregnant) can also continue caring for patients with telemedicine while maintaining safety. As schools close, telemedicine can help providers navigate the challenge between patient care and childcare responsibilities.

The basic element of telemedicine involves a computer or monitor with an internet-connected camera and a HIPAA-compliant video application, but implementation can vary.

Recent changes have allowed the use of popular video chat software such as FaceTime, Skype, or Google Duo for patient interactions; with a tablet attached to a stand, organizations can easily create a mobile telemedicine workstation. Larger monitors or mounted screens can be used in patient areas where portability is not required. A strong network infrastructure and robust IT support are also necessary; as of 2016, 24 million Americans did not have broadband access, and even areas that do can struggle with wireless connectivity in hospitals with thick concrete walls and lack of wi-fi extenders.¹¹

With the addition of a digital stethoscope, hospitalists can perform a thorough history and physical with the aid of bedside staff. This requires dedicated training for all members of the care team in order to optimize the virtual hospitalist’s “telepresence” and create a seamless patient experience. Provider education is imperative: Creating a virtual telepresence is essential in building a strong provider-patient relationship. We have used simulation training to prepare new telehospitalists.

An overlooked, but important, operational requirement is patient education and awareness. In the absence of introduction and onboarding, telemedicine can be viewed by patients as impersonal; however, with proper implementation, high patient satisfaction has been demonstrated in other virtual care experiences.¹²

Though several health systems offer “tele-ICU” services, the number of hospital medicine programs is more limited. The cost of building a program can be significant, with outlays for equipment, IT support, provider salaries, and training. While all 50 states and the District of Columbia cover some form of fee-for-service live video with Medicaid, only 40, along with DC, have parity laws with commercial payors. Medicare has historically had more restrictions, limiting covered services to specific types of originating sites in certain geographic areas. Furthermore, growth of telehospitalist programs has been hampered by the lack of reimbursement for “primary care services.”¹³

With passage of the Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020, geographic and site restrictions have been waived for Medicare reimbursement.¹⁴ Providers must still demonstrate a prior relationship with patients, which requires at least one encounter with the patient in the past 3 years by the same provider or one with a similar tax identification number (TIN). All hospitalists within our group are identified with a common TIN, which helps to meet this requirement for patient with recent admissions. However, clear guidance on reimbursement for primary care services by acute care providers is still lacking. As the utility of telemedicine is demonstrated in the hospital setting, we hope further changes may be enacted.

Organizations must properly credential and privilege telehospitalists. Telemedicine services may fall under either core or “delegated” privileges depending on the individual hospital. Additionally, while malpractice insurance does typically cover telemedicine services, each organization should verify this with their particular carrier.

The COVID-19 pandemic has created a systemic challenge for healthcare systems across the nation. As hospitalists continue to be on the front lines, organizations can leverage telemedicine to support their patients, protect their clinicians, and conserve scarce resources. Building out a virtual care program is intricate and requires significant operational support. Laying the groundwork now can prepare institutions to provide necessary care for patients, not just in the current pandemic, but in numerous emergency health care situations in the future.

The field of telemedicine, in which clinicians use remote evaluation and monitoring to diagnose and treat patients, has grown substantially over the past decade. Its roles in acute care medicine settings are diverse, including virtual intensive care unit (ICU) care, after-­hours medical admissions, cross coverage, and, most aptly, disaster management.¹

At HealthPartners, a large integrated healthcare delivery and financing system based in the Twin Cities region of Minnesota, we have used provider-initiated telemedicine in hospital medicine for more than 2 years, providing evening and nighttime hospitalist coverage to our rural hospitals. We additionally provide a 24/7 nurse practitioner-staffed virtual clinic called Virtuwell.² Because we are now immersed in a global pandemic, we have taken steps to bolster our telemedicine infrastructure to meet increasing needs.

SARS-CoV-2, the causative agent of COVID-19, is a novel coronavirus with the capability to cause severe illness in roughly 14% of those infected.³ According to some estimates, the virus may infect up to 60% of the US population in the next year.⁴ As the pandemic looms over the country and the healthcare community, telemedicine can offer tools to help respond to this crisis. Healthcare systems leveraging telemedicine for patient care will gain several advantages, including workforce sustainability, reduction of provider burnout, limitation of provider exposure, and reduction of personal protective equipment (PPE) waste (Table). Telemedicine can also facilitate staffing of both large and small facilities that find themselves overwhelmed with pandemic-related patient overload (PRPO). Although telemedicine holds promise for pandemic response, this technology has limitations. It requires robust IT infrastructure, training of both nurses and physicians, and modifications to integrate within hospital workflows. In this article, we summarize key clinical needs that telemedicine can meet, implementation challenges, and important business considerations.

Our organization currently uses telemedicine to provide after-­hours hospital medicine coverage from 6 pm to 8 am at five rural and critical-access hospitals. We utilize commercial telemedicine carts on-site at hospitals and company-provided laptops at home. Our video visits are completed using enterprise video software and commercial digital stethoscopes. In the past month, we have increased our capacity, including at two large tertiary-care hospitals, by adding web cameras to existing mobile workstations and purchasing additional laptops for new telemedicine providers. Major barriers we encountered included cost, credentialing providers across multiple sites, and equipment testing. However, with close coordination with executive leadership, use of disaster credentialing, and robust IT support, we have been able to move past these obstacles in expanding our telemedicine infrastructure for support during this crucial time.

Patient Triage

Limiting exposure in the community and in the acute care setting is key to “flattening the curve” in pandemics.⁵ Triaging patients by telephone and online surveys is an important method to prevent high-risk patients from exposing others to infection. For example, since March 9, 2020, over 20,000 patients have called in weekly for COVID-19 screening. Although our organization introduced drive-up testing to reduce exposure, patients are still presenting to our clinics and emergency rooms in need of screening and testing. In several of our clinics, patients have been roomed alone to facilitate screening in the room by use of Google Duo, a free video chat product. Rooms with telemedicine capabilities allow patients with potentially communicable infections to be evaluated and observed while avoiding the risk of viral transmission. Additional considerations could include self-administered nasal swabs; although this has comparable efficacy to staff-administered swabs,⁶ it has not yet been implemented in our clinics.

Direct Care

Virtual care, specifically synchronous video and audio provider-­initiated services, is a well-established modality to provide direct care to patients in acute care and ambulatory settings.⁷ Telemedicine can be deployed to care for hospitalized patients in most locations as long as they meet the operational requirements described below. With a bedside nurse or other facilitator, patients can be interviewed and examined using a high definition camera and digital peripherals, including stethoscopes, otoscopes, ophthalmoscopes, and dermatoscopes. COVID-19 patients or patients under investigation may be seen in this manner. In-person visits should remain part of patients’ care as an important part of the provider-patient relationship⁸; however, telemedicine could still be deployed to provide direct care and monitoring to these patients while minimizing exposure to healthcare personnel. Additionally, telemedicine can be used for specialist consultations that are likely in high demand with COVID-19, including infectious disease, cardiology, and pulmonology.

Exposure Reduction and Resource Allocation

Currently in the United States there are concerns for shortages of PPE including surgical masks and N95 respirators. Telemedicine can reduce provider exposure, increase provider efficiency, and curtail PPE utilization by minimizing the number and frequency of in-room visits while still allowing virtual visits for direct patient care. For instance, our nursing staff is currently using telemedicine to conduct hourly rounding and limit unnecessary in-room visits.

We recommend keeping telemedicine equipment within individual isolation rooms intended for COVID-19 patients in order to eliminate the need for repeated cleaning. For other patients, a mobile cart could be used. Most commercial video software can autoanswer calls to allow for staff-free history taking. For a thorough physical exam, a bedside facilitator is need for use of digital stethoscopes and similar peripherals.

Provider Shortages and Reducing Burnout

Because SARS-CoV-2 is a highly contagious pathogen that can spread prior to symptom presentation, current CDC guidelines recommend self-monitoring at home for health care workers who have a healthcare-related exposure to a COVID-19 patient.⁹ This can leave significant gaps in coverage for healthcare systems. For example, in Vacaville, California, one positive case resulted in over 200 health care workers unable to work on site.¹⁰

Large volumes of acutely ill patients, coupled with the risk of ill or quarantined providers, means provider shortages due to PRPO are likely to occur and threaten hospitals’ ability to care for patients with or without COVID-19. Furthermore, given increased patient loads, frontline staff are at exceptionally high risk of burnout in pandemic situations. Hospital medicine teams will need contingency plans to meet the needs. Using telemedicine to protect the workforce and maintain staffing levels will reduce that risk.

Telehospitalists can see and examine patients, write orders, and maintain patient service lines much like in-person providers. Recently, we have used it when providers are ill or self-monitoring. In multisite systems, telehospitalists who are privileged in multiple hospitals can be efficiently deployed to meet patient care needs and relieve overburdened providers across hundreds of miles or more.

Enabling patient rooms for telemedicine allows telehospitalists and other providers to see hospitalized patients. Furthermore, quarantined hospitalists can continue to work and support in-person clinical services during PRPO. Providers in high-risk groups (eg, older, immunosuppressed, pregnant) can also continue caring for patients with telemedicine while maintaining safety. As schools close, telemedicine can help providers navigate the challenge between patient care and childcare responsibilities.

The basic element of telemedicine involves a computer or monitor with an internet-connected camera and a HIPAA-compliant video application, but implementation can vary.

Recent changes have allowed the use of popular video chat software such as FaceTime, Skype, or Google Duo for patient interactions; with a tablet attached to a stand, organizations can easily create a mobile telemedicine workstation. Larger monitors or mounted screens can be used in patient areas where portability is not required. A strong network infrastructure and robust IT support are also necessary; as of 2016, 24 million Americans did not have broadband access, and even areas that do can struggle with wireless connectivity in hospitals with thick concrete walls and lack of wi-fi extenders.¹¹

With the addition of a digital stethoscope, hospitalists can perform a thorough history and physical with the aid of bedside staff. This requires dedicated training for all members of the care team in order to optimize the virtual hospitalist’s “telepresence” and create a seamless patient experience. Provider education is imperative: Creating a virtual telepresence is essential in building a strong provider-patient relationship. We have used simulation training to prepare new telehospitalists.

An overlooked, but important, operational requirement is patient education and awareness. In the absence of introduction and onboarding, telemedicine can be viewed by patients as impersonal; however, with proper implementation, high patient satisfaction has been demonstrated in other virtual care experiences.¹²

Though several health systems offer “tele-ICU” services, the number of hospital medicine programs is more limited. The cost of building a program can be significant, with outlays for equipment, IT support, provider salaries, and training. While all 50 states and the District of Columbia cover some form of fee-for-service live video with Medicaid, only 40, along with DC, have parity laws with commercial payors. Medicare has historically had more restrictions, limiting covered services to specific types of originating sites in certain geographic areas. Furthermore, growth of telehospitalist programs has been hampered by the lack of reimbursement for “primary care services.”¹³

With passage of the Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020, geographic and site restrictions have been waived for Medicare reimbursement.¹⁴ Providers must still demonstrate a prior relationship with patients, which requires at least one encounter with the patient in the past 3 years by the same provider or one with a similar tax identification number (TIN). All hospitalists within our group are identified with a common TIN, which helps to meet this requirement for patient with recent admissions. However, clear guidance on reimbursement for primary care services by acute care providers is still lacking. As the utility of telemedicine is demonstrated in the hospital setting, we hope further changes may be enacted.

Organizations must properly credential and privilege telehospitalists. Telemedicine services may fall under either core or “delegated” privileges depending on the individual hospital. Additionally, while malpractice insurance does typically cover telemedicine services, each organization should verify this with their particular carrier.

The COVID-19 pandemic has created a systemic challenge for healthcare systems across the nation. As hospitalists continue to be on the front lines, organizations can leverage telemedicine to support their patients, protect their clinicians, and conserve scarce resources. Building out a virtual care program is intricate and requires significant operational support. Laying the groundwork now can prepare institutions to provide necessary care for patients, not just in the current pandemic, but in numerous emergency health care situations in the future.

The field of telemedicine, in which clinicians use remote evaluation and monitoring to diagnose and treat patients, has grown substantially over the past decade. Its roles in acute care medicine settings are diverse, including virtual intensive care unit (ICU) care, after-­hours medical admissions, cross coverage, and, most aptly, disaster management.¹

At HealthPartners, a large integrated healthcare delivery and financing system based in the Twin Cities region of Minnesota, we have used provider-initiated telemedicine in hospital medicine for more than 2 years, providing evening and nighttime hospitalist coverage to our rural hospitals. We additionally provide a 24/7 nurse practitioner-staffed virtual clinic called Virtuwell.² Because we are now immersed in a global pandemic, we have taken steps to bolster our telemedicine infrastructure to meet increasing needs.

SARS-CoV-2, the causative agent of COVID-19, is a novel coronavirus with the capability to cause severe illness in roughly 14% of those infected.³ According to some estimates, the virus may infect up to 60% of the US population in the next year.⁴ As the pandemic looms over the country and the healthcare community, telemedicine can offer tools to help respond to this crisis. Healthcare systems leveraging telemedicine for patient care will gain several advantages, including workforce sustainability, reduction of provider burnout, limitation of provider exposure, and reduction of personal protective equipment (PPE) waste (Table). Telemedicine can also facilitate staffing of both large and small facilities that find themselves overwhelmed with pandemic-related patient overload (PRPO). Although telemedicine holds promise for pandemic response, this technology has limitations. It requires robust IT infrastructure, training of both nurses and physicians, and modifications to integrate within hospital workflows. In this article, we summarize key clinical needs that telemedicine can meet, implementation challenges, and important business considerations.

Our organization currently uses telemedicine to provide after-­hours hospital medicine coverage from 6 pm to 8 am at five rural and critical-access hospitals. We utilize commercial telemedicine carts on-site at hospitals and company-provided laptops at home. Our video visits are completed using enterprise video software and commercial digital stethoscopes. In the past month, we have increased our capacity, including at two large tertiary-care hospitals, by adding web cameras to existing mobile workstations and purchasing additional laptops for new telemedicine providers. Major barriers we encountered included cost, credentialing providers across multiple sites, and equipment testing. However, with close coordination with executive leadership, use of disaster credentialing, and robust IT support, we have been able to move past these obstacles in expanding our telemedicine infrastructure for support during this crucial time.

Patient Triage

Limiting exposure in the community and in the acute care setting is key to “flattening the curve” in pandemics.⁵ Triaging patients by telephone and online surveys is an important method to prevent high-risk patients from exposing others to infection. For example, since March 9, 2020, over 20,000 patients have called in weekly for COVID-19 screening. Although our organization introduced drive-up testing to reduce exposure, patients are still presenting to our clinics and emergency rooms in need of screening and testing. In several of our clinics, patients have been roomed alone to facilitate screening in the room by use of Google Duo, a free video chat product. Rooms with telemedicine capabilities allow patients with potentially communicable infections to be evaluated and observed while avoiding the risk of viral transmission. Additional considerations could include self-administered nasal swabs; although this has comparable efficacy to staff-administered swabs,⁶ it has not yet been implemented in our clinics.

Direct Care

Virtual care, specifically synchronous video and audio provider-­initiated services, is a well-established modality to provide direct care to patients in acute care and ambulatory settings.⁷ Telemedicine can be deployed to care for hospitalized patients in most locations as long as they meet the operational requirements described below. With a bedside nurse or other facilitator, patients can be interviewed and examined using a high definition camera and digital peripherals, including stethoscopes, otoscopes, ophthalmoscopes, and dermatoscopes. COVID-19 patients or patients under investigation may be seen in this manner. In-person visits should remain part of patients’ care as an important part of the provider-patient relationship⁸; however, telemedicine could still be deployed to provide direct care and monitoring to these patients while minimizing exposure to healthcare personnel. Additionally, telemedicine can be used for specialist consultations that are likely in high demand with COVID-19, including infectious disease, cardiology, and pulmonology.

Exposure Reduction and Resource Allocation

Currently in the United States there are concerns for shortages of PPE including surgical masks and N95 respirators. Telemedicine can reduce provider exposure, increase provider efficiency, and curtail PPE utilization by minimizing the number and frequency of in-room visits while still allowing virtual visits for direct patient care. For instance, our nursing staff is currently using telemedicine to conduct hourly rounding and limit unnecessary in-room visits.

We recommend keeping telemedicine equipment within individual isolation rooms intended for COVID-19 patients in order to eliminate the need for repeated cleaning. For other patients, a mobile cart could be used. Most commercial video software can autoanswer calls to allow for staff-free history taking. For a thorough physical exam, a bedside facilitator is need for use of digital stethoscopes and similar peripherals.

Provider Shortages and Reducing Burnout

Because SARS-CoV-2 is a highly contagious pathogen that can spread prior to symptom presentation, current CDC guidelines recommend self-monitoring at home for health care workers who have a healthcare-related exposure to a COVID-19 patient.⁹ This can leave significant gaps in coverage for healthcare systems. For example, in Vacaville, California, one positive case resulted in over 200 health care workers unable to work on site.¹⁰

Large volumes of acutely ill patients, coupled with the risk of ill or quarantined providers, means provider shortages due to PRPO are likely to occur and threaten hospitals’ ability to care for patients with or without COVID-19. Furthermore, given increased patient loads, frontline staff are at exceptionally high risk of burnout in pandemic situations. Hospital medicine teams will need contingency plans to meet the needs. Using telemedicine to protect the workforce and maintain staffing levels will reduce that risk.

Telehospitalists can see and examine patients, write orders, and maintain patient service lines much like in-person providers. Recently, we have used it when providers are ill or self-monitoring. In multisite systems, telehospitalists who are privileged in multiple hospitals can be efficiently deployed to meet patient care needs and relieve overburdened providers across hundreds of miles or more.

Enabling patient rooms for telemedicine allows telehospitalists and other providers to see hospitalized patients. Furthermore, quarantined hospitalists can continue to work and support in-person clinical services during PRPO. Providers in high-risk groups (eg, older, immunosuppressed, pregnant) can also continue caring for patients with telemedicine while maintaining safety. As schools close, telemedicine can help providers navigate the challenge between patient care and childcare responsibilities.

The basic element of telemedicine involves a computer or monitor with an internet-connected camera and a HIPAA-compliant video application, but implementation can vary.

Recent changes have allowed the use of popular video chat software such as FaceTime, Skype, or Google Duo for patient interactions; with a tablet attached to a stand, organizations can easily create a mobile telemedicine workstation. Larger monitors or mounted screens can be used in patient areas where portability is not required. A strong network infrastructure and robust IT support are also necessary; as of 2016, 24 million Americans did not have broadband access, and even areas that do can struggle with wireless connectivity in hospitals with thick concrete walls and lack of wi-fi extenders.¹¹

With the addition of a digital stethoscope, hospitalists can perform a thorough history and physical with the aid of bedside staff. This requires dedicated training for all members of the care team in order to optimize the virtual hospitalist’s “telepresence” and create a seamless patient experience. Provider education is imperative: Creating a virtual telepresence is essential in building a strong provider-patient relationship. We have used simulation training to prepare new telehospitalists.

An overlooked, but important, operational requirement is patient education and awareness. In the absence of introduction and onboarding, telemedicine can be viewed by patients as impersonal; however, with proper implementation, high patient satisfaction has been demonstrated in other virtual care experiences.¹²

Though several health systems offer “tele-ICU” services, the number of hospital medicine programs is more limited. The cost of building a program can be significant, with outlays for equipment, IT support, provider salaries, and training. While all 50 states and the District of Columbia cover some form of fee-for-service live video with Medicaid, only 40, along with DC, have parity laws with commercial payors. Medicare has historically had more restrictions, limiting covered services to specific types of originating sites in certain geographic areas. Furthermore, growth of telehospitalist programs has been hampered by the lack of reimbursement for “primary care services.”¹³

With passage of the Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020, geographic and site restrictions have been waived for Medicare reimbursement.¹⁴ Providers must still demonstrate a prior relationship with patients, which requires at least one encounter with the patient in the past 3 years by the same provider or one with a similar tax identification number (TIN). All hospitalists within our group are identified with a common TIN, which helps to meet this requirement for patient with recent admissions. However, clear guidance on reimbursement for primary care services by acute care providers is still lacking. As the utility of telemedicine is demonstrated in the hospital setting, we hope further changes may be enacted.

Organizations must properly credential and privilege telehospitalists. Telemedicine services may fall under either core or “delegated” privileges depending on the individual hospital. Additionally, while malpractice insurance does typically cover telemedicine services, each organization should verify this with their particular carrier.

The COVID-19 pandemic has created a systemic challenge for healthcare systems across the nation. As hospitalists continue to be on the front lines, organizations can leverage telemedicine to support their patients, protect their clinicians, and conserve scarce resources. Building out a virtual care program is intricate and requires significant operational support. Laying the groundwork now can prepare institutions to provide necessary care for patients, not just in the current pandemic, but in numerous emergency health care situations in the future.

On March 25, 2003, I was in Vancouver at my niece’s bat mitzvah when I saw a picture of my hospital in Toronto on the television news; a story about SARS patients in Toronto. Until then, SARS had been a distant event happening in mainland China and Hong Kong; it had been something that seemed very far away and theoretical. When I returned to Toronto, we had clusters of cases in several hospitals and healthcare workers were falling ill. I was the Physician in Chief at one of those hospitals and was responsible for the clinical care delivered by physicians in the Department of Medicine. So the burden of figuring out what we were going to do fell on me and the other members of the hospital leadership team.

As the outbreak evolved, we only knew a few things. It was a respiratory infection, likely viral, with a very high mortality rate, compared with most other viral respiratory infections. We learned the hard way that, while it was mostly transmitted by droplets, some patients were able to widely transmit it through the air, and therefore likely through ventilation systems. We knew that most infections were occurring in hospitals but there was also community spread at events like funerals. We had no test to confirm the presence of the virus and, indeed, only figured out it was a coronavirus well into the outbreak. Diagnoses were made using clinical criteria; this uncertainty was a major source of anxiety about potential community spread without direct links to known cases. We had no idea how long it was going to last, nor did we know how it would end. We were entering uncharted territory.

Decisions had to be made. Which patients needed isolation, and which did not? We made mistakes early on that caused hundreds of healthcare workers and people to be quarantined (complete isolation) for 10 days; this was a difficult situation for them, their families, and the people who had to replace them in the workplace.

Within a very short period we changed our way of life in hospitals. We screened everyone who entered with questionnaires and measured their temperatures. Once entering the hospital, we all wore N95 masks in public spaces and when in a room with another person—not just patients. We all got sore throats from wearing the masks 10 hours a day. All patients were placed in respiratory precautions, which meant that, any time we entered their rooms, we had to don all the personal protective equipment (PPE). Yet we didn’t run out of supplies. When a member of a provincial leadership team fell ill with SARS shortly after attending an in-person meeting of the committee, all the other members went into quarantine. As a result, we stopped having leadership team meetings in person, and mostly stayed in our own offices, communicating by phone and email.

The hospital took on a bizarre atmosphere: everyone in masks and little face-to-face contact. Yet outside the hospital, life went on mostly as normal. Some people wore masks on the street, but public events and businesses stayed open. Some healthcare workers were shunned in the community out of fear. But I went to another bat mitzvah and even a Stanley Cup playoff game at the height of the outbreak. Only healthcare workers were asked to stop meeting in large groups. The contrast for me was striking.

The Ontario Ministry of Health started a daily noon hour phone conference call; one physician and one administrator from every hospital in the province were on the call. I attended those for my hospital and, because I knew or taught many of the people on the line, was quickly asked to chair the calls. They were incredibly important and were a source of information exchange and emotional support for all of us. Before each call, I spoke with a person from Toronto Public Health who updated me on the number of cases and deaths. I needed to absorb that information before the calls to maintain my composure when she told the rest of the group. At times I could hear the fear in people’s voices as they described the clinical course of their patients.

Because I chaired the calls, I was asked to coordinate the study that documented the clinical outcomes of all the patients in the hopes that we could distinguish it from other common respiratory syndromes. With the help of my colleagues in the 11 hospitals that treated SARS patients, the ethics review boards, medical records personnel who copied the charts, Christopher Booth, MD, (a second- year resident at the time who headed the study), and a few medical students we were able to go from the idea to do the study to electronic publication in JAMA in 30 days.¹ It was JAMA’s first experience with rapid review, and the editors there were very helpful. Working on this study was very therapeutic; it allowed me to feel I was doing something that could help.

I was scared—both for my own health and the health of my family, but also terribly frightened for the health of the people who worked here. When I went home every night, I looked at the people on the street and wondered how many would still be there a few months later. And then it all ended. (Actually, it ended twice; we let up a bit too early because we so wanted it to be over.)

The COVID-19 pandemic has many similarities, but there are also significant differences. The most obvious is that because there is more community spread, life outside the hospital is much more severely disrupted. Countries have responded by sliding into more and more practices that try to limit person-to-person spread. First travel restrictions from other countries, then moral suasion to promote social distancing (which is really just physical distancing), then closing schools and nonessential businesses, and finally complete lock downs.

These events have spurred panic buying of some items (hand sanitizer, toilet paper, masks), and the fear of major disruptions of the supply chain for things like food. SARS was much more limited in its overall economic effect, though the WHO precautionary travel advisory against nonessential travel to Toronto, which lasted for only 1 week, resulted in a long-lasting reduction in tourism and a hit to the theatre business in our city.

The internet and social media have made it easier to disseminate valuable information and instructions, while at the same time easier to spread false information. But we had a lot of false information during SARS, too. One of the biggest differences for the United States (which was almost unaffected by SARS) is that the current extreme political divide creates two separate tracks of information and beliefs. A united message is very important.

Finally, the shortage of PPE in some jurisdictions, which was not an issue in Toronto during SARS, has severely heightened the fear for healthcare workers. In 2003, we also had lots of discussion about the tension between our professional duty and the safety of healthcare workers and their families (many of us separated ourselves from our families in our own homes while working clinically). To my recollection, two nurses and one physician died of SARS in Toronto. But when hospitals actually run out of PPE—something that is happening with COVID-19—those discussions take on a much more ominous tone.

In my opinion, SARS was a dry run for us in Toronto and the other places in the world that it affected (Taiwan, Hong Kong, Singapore); one that helped us prepare in advance and will help us cope with COVID-19. But what did I personally learn from my SARS experience?

First, I learned that accurate information in these kinds of situations is hard to come by. We heard lots of rumors from people all over the world. But when I found that it was very difficult for me to figure out exactly what was going on in my own hospital (eg, who was in contact with people who fell ill or went into quarantine, how patients were faring), I realized that figuring out what was happening half way around the world from news reports was near impossible. I learned to wait for official announcements.

Second, I learned that talking to my colleagues was both therapeutic—providing emotional support and an outlet for feelings—and anxiety provoking when we overreacted to rumors.

Third, I learned that, like others, I was susceptible to exhibiting obsessive behaviors in an attempt to establish control over uncertainty. Constantly washing my hands, checking my temperature, and seeking reassuring facts from others only worked to calm me for a few minutes. And then I felt the need to do it again. This time I find myself checking my twitter account constantly; half afraid I will see something frightening, half looking for good news from people I trust. I now recognize this behavior and it helps me contain it.

Fourth, I learned that events that occurred remotely had much less effect on everyone than those that occurred close by. Having two people I knew get SARS, and then learning they recovered was perhaps the most meaningful event for me during the entire episode.

Finally, I learned that in the end I and the people I care about survived—nothing bad happened to us. The world did not end after SARS. It took me about a year, including some time with a terrific psychiatrist, to realize I was safe after all. And that realization is what I am most hanging on to today.

Acknowledgments

Sanjay Saint (University of Michigan), Christopher Booth (Queens University), and Sagar Rohailla (University of Toronto) provided comments on an earlier draft. None were compensated for doing so.

On March 25, 2003, I was in Vancouver at my niece’s bat mitzvah when I saw a picture of my hospital in Toronto on the television news; a story about SARS patients in Toronto. Until then, SARS had been a distant event happening in mainland China and Hong Kong; it had been something that seemed very far away and theoretical. When I returned to Toronto, we had clusters of cases in several hospitals and healthcare workers were falling ill. I was the Physician in Chief at one of those hospitals and was responsible for the clinical care delivered by physicians in the Department of Medicine. So the burden of figuring out what we were going to do fell on me and the other members of the hospital leadership team.

As the outbreak evolved, we only knew a few things. It was a respiratory infection, likely viral, with a very high mortality rate, compared with most other viral respiratory infections. We learned the hard way that, while it was mostly transmitted by droplets, some patients were able to widely transmit it through the air, and therefore likely through ventilation systems. We knew that most infections were occurring in hospitals but there was also community spread at events like funerals. We had no test to confirm the presence of the virus and, indeed, only figured out it was a coronavirus well into the outbreak. Diagnoses were made using clinical criteria; this uncertainty was a major source of anxiety about potential community spread without direct links to known cases. We had no idea how long it was going to last, nor did we know how it would end. We were entering uncharted territory.

Decisions had to be made. Which patients needed isolation, and which did not? We made mistakes early on that caused hundreds of healthcare workers and people to be quarantined (complete isolation) for 10 days; this was a difficult situation for them, their families, and the people who had to replace them in the workplace.

Within a very short period we changed our way of life in hospitals. We screened everyone who entered with questionnaires and measured their temperatures. Once entering the hospital, we all wore N95 masks in public spaces and when in a room with another person—not just patients. We all got sore throats from wearing the masks 10 hours a day. All patients were placed in respiratory precautions, which meant that, any time we entered their rooms, we had to don all the personal protective equipment (PPE). Yet we didn’t run out of supplies. When a member of a provincial leadership team fell ill with SARS shortly after attending an in-person meeting of the committee, all the other members went into quarantine. As a result, we stopped having leadership team meetings in person, and mostly stayed in our own offices, communicating by phone and email.

The hospital took on a bizarre atmosphere: everyone in masks and little face-to-face contact. Yet outside the hospital, life went on mostly as normal. Some people wore masks on the street, but public events and businesses stayed open. Some healthcare workers were shunned in the community out of fear. But I went to another bat mitzvah and even a Stanley Cup playoff game at the height of the outbreak. Only healthcare workers were asked to stop meeting in large groups. The contrast for me was striking.

The Ontario Ministry of Health started a daily noon hour phone conference call; one physician and one administrator from every hospital in the province were on the call. I attended those for my hospital and, because I knew or taught many of the people on the line, was quickly asked to chair the calls. They were incredibly important and were a source of information exchange and emotional support for all of us. Before each call, I spoke with a person from Toronto Public Health who updated me on the number of cases and deaths. I needed to absorb that information before the calls to maintain my composure when she told the rest of the group. At times I could hear the fear in people’s voices as they described the clinical course of their patients.

Because I chaired the calls, I was asked to coordinate the study that documented the clinical outcomes of all the patients in the hopes that we could distinguish it from other common respiratory syndromes. With the help of my colleagues in the 11 hospitals that treated SARS patients, the ethics review boards, medical records personnel who copied the charts, Christopher Booth, MD, (a second- year resident at the time who headed the study), and a few medical students we were able to go from the idea to do the study to electronic publication in JAMA in 30 days.¹ It was JAMA’s first experience with rapid review, and the editors there were very helpful. Working on this study was very therapeutic; it allowed me to feel I was doing something that could help.

I was scared—both for my own health and the health of my family, but also terribly frightened for the health of the people who worked here. When I went home every night, I looked at the people on the street and wondered how many would still be there a few months later. And then it all ended. (Actually, it ended twice; we let up a bit too early because we so wanted it to be over.)

The COVID-19 pandemic has many similarities, but there are also significant differences. The most obvious is that because there is more community spread, life outside the hospital is much more severely disrupted. Countries have responded by sliding into more and more practices that try to limit person-to-person spread. First travel restrictions from other countries, then moral suasion to promote social distancing (which is really just physical distancing), then closing schools and nonessential businesses, and finally complete lock downs.

These events have spurred panic buying of some items (hand sanitizer, toilet paper, masks), and the fear of major disruptions of the supply chain for things like food. SARS was much more limited in its overall economic effect, though the WHO precautionary travel advisory against nonessential travel to Toronto, which lasted for only 1 week, resulted in a long-lasting reduction in tourism and a hit to the theatre business in our city.

The internet and social media have made it easier to disseminate valuable information and instructions, while at the same time easier to spread false information. But we had a lot of false information during SARS, too. One of the biggest differences for the United States (which was almost unaffected by SARS) is that the current extreme political divide creates two separate tracks of information and beliefs. A united message is very important.

Finally, the shortage of PPE in some jurisdictions, which was not an issue in Toronto during SARS, has severely heightened the fear for healthcare workers. In 2003, we also had lots of discussion about the tension between our professional duty and the safety of healthcare workers and their families (many of us separated ourselves from our families in our own homes while working clinically). To my recollection, two nurses and one physician died of SARS in Toronto. But when hospitals actually run out of PPE—something that is happening with COVID-19—those discussions take on a much more ominous tone.

In my opinion, SARS was a dry run for us in Toronto and the other places in the world that it affected (Taiwan, Hong Kong, Singapore); one that helped us prepare in advance and will help us cope with COVID-19. But what did I personally learn from my SARS experience?

First, I learned that accurate information in these kinds of situations is hard to come by. We heard lots of rumors from people all over the world. But when I found that it was very difficult for me to figure out exactly what was going on in my own hospital (eg, who was in contact with people who fell ill or went into quarantine, how patients were faring), I realized that figuring out what was happening half way around the world from news reports was near impossible. I learned to wait for official announcements.

Second, I learned that talking to my colleagues was both therapeutic—providing emotional support and an outlet for feelings—and anxiety provoking when we overreacted to rumors.

Third, I learned that, like others, I was susceptible to exhibiting obsessive behaviors in an attempt to establish control over uncertainty. Constantly washing my hands, checking my temperature, and seeking reassuring facts from others only worked to calm me for a few minutes. And then I felt the need to do it again. This time I find myself checking my twitter account constantly; half afraid I will see something frightening, half looking for good news from people I trust. I now recognize this behavior and it helps me contain it.

Fourth, I learned that events that occurred remotely had much less effect on everyone than those that occurred close by. Having two people I knew get SARS, and then learning they recovered was perhaps the most meaningful event for me during the entire episode.

Finally, I learned that in the end I and the people I care about survived—nothing bad happened to us. The world did not end after SARS. It took me about a year, including some time with a terrific psychiatrist, to realize I was safe after all. And that realization is what I am most hanging on to today.

Acknowledgments

Sanjay Saint (University of Michigan), Christopher Booth (Queens University), and Sagar Rohailla (University of Toronto) provided comments on an earlier draft. None were compensated for doing so.

On March 25, 2003, I was in Vancouver at my niece’s bat mitzvah when I saw a picture of my hospital in Toronto on the television news; a story about SARS patients in Toronto. Until then, SARS had been a distant event happening in mainland China and Hong Kong; it had been something that seemed very far away and theoretical. When I returned to Toronto, we had clusters of cases in several hospitals and healthcare workers were falling ill. I was the Physician in Chief at one of those hospitals and was responsible for the clinical care delivered by physicians in the Department of Medicine. So the burden of figuring out what we were going to do fell on me and the other members of the hospital leadership team.

As the outbreak evolved, we only knew a few things. It was a respiratory infection, likely viral, with a very high mortality rate, compared with most other viral respiratory infections. We learned the hard way that, while it was mostly transmitted by droplets, some patients were able to widely transmit it through the air, and therefore likely through ventilation systems. We knew that most infections were occurring in hospitals but there was also community spread at events like funerals. We had no test to confirm the presence of the virus and, indeed, only figured out it was a coronavirus well into the outbreak. Diagnoses were made using clinical criteria; this uncertainty was a major source of anxiety about potential community spread without direct links to known cases. We had no idea how long it was going to last, nor did we know how it would end. We were entering uncharted territory.

Decisions had to be made. Which patients needed isolation, and which did not? We made mistakes early on that caused hundreds of healthcare workers and people to be quarantined (complete isolation) for 10 days; this was a difficult situation for them, their families, and the people who had to replace them in the workplace.

Within a very short period we changed our way of life in hospitals. We screened everyone who entered with questionnaires and measured their temperatures. Once entering the hospital, we all wore N95 masks in public spaces and when in a room with another person—not just patients. We all got sore throats from wearing the masks 10 hours a day. All patients were placed in respiratory precautions, which meant that, any time we entered their rooms, we had to don all the personal protective equipment (PPE). Yet we didn’t run out of supplies. When a member of a provincial leadership team fell ill with SARS shortly after attending an in-person meeting of the committee, all the other members went into quarantine. As a result, we stopped having leadership team meetings in person, and mostly stayed in our own offices, communicating by phone and email.

The hospital took on a bizarre atmosphere: everyone in masks and little face-to-face contact. Yet outside the hospital, life went on mostly as normal. Some people wore masks on the street, but public events and businesses stayed open. Some healthcare workers were shunned in the community out of fear. But I went to another bat mitzvah and even a Stanley Cup playoff game at the height of the outbreak. Only healthcare workers were asked to stop meeting in large groups. The contrast for me was striking.

The Ontario Ministry of Health started a daily noon hour phone conference call; one physician and one administrator from every hospital in the province were on the call. I attended those for my hospital and, because I knew or taught many of the people on the line, was quickly asked to chair the calls. They were incredibly important and were a source of information exchange and emotional support for all of us. Before each call, I spoke with a person from Toronto Public Health who updated me on the number of cases and deaths. I needed to absorb that information before the calls to maintain my composure when she told the rest of the group. At times I could hear the fear in people’s voices as they described the clinical course of their patients.

Because I chaired the calls, I was asked to coordinate the study that documented the clinical outcomes of all the patients in the hopes that we could distinguish it from other common respiratory syndromes. With the help of my colleagues in the 11 hospitals that treated SARS patients, the ethics review boards, medical records personnel who copied the charts, Christopher Booth, MD, (a second- year resident at the time who headed the study), and a few medical students we were able to go from the idea to do the study to electronic publication in JAMA in 30 days.¹ It was JAMA’s first experience with rapid review, and the editors there were very helpful. Working on this study was very therapeutic; it allowed me to feel I was doing something that could help.

I was scared—both for my own health and the health of my family, but also terribly frightened for the health of the people who worked here. When I went home every night, I looked at the people on the street and wondered how many would still be there a few months later. And then it all ended. (Actually, it ended twice; we let up a bit too early because we so wanted it to be over.)

The COVID-19 pandemic has many similarities, but there are also significant differences. The most obvious is that because there is more community spread, life outside the hospital is much more severely disrupted. Countries have responded by sliding into more and more practices that try to limit person-to-person spread. First travel restrictions from other countries, then moral suasion to promote social distancing (which is really just physical distancing), then closing schools and nonessential businesses, and finally complete lock downs.

These events have spurred panic buying of some items (hand sanitizer, toilet paper, masks), and the fear of major disruptions of the supply chain for things like food. SARS was much more limited in its overall economic effect, though the WHO precautionary travel advisory against nonessential travel to Toronto, which lasted for only 1 week, resulted in a long-lasting reduction in tourism and a hit to the theatre business in our city.

The internet and social media have made it easier to disseminate valuable information and instructions, while at the same time easier to spread false information. But we had a lot of false information during SARS, too. One of the biggest differences for the United States (which was almost unaffected by SARS) is that the current extreme political divide creates two separate tracks of information and beliefs. A united message is very important.

Finally, the shortage of PPE in some jurisdictions, which was not an issue in Toronto during SARS, has severely heightened the fear for healthcare workers. In 2003, we also had lots of discussion about the tension between our professional duty and the safety of healthcare workers and their families (many of us separated ourselves from our families in our own homes while working clinically). To my recollection, two nurses and one physician died of SARS in Toronto. But when hospitals actually run out of PPE—something that is happening with COVID-19—those discussions take on a much more ominous tone.

In my opinion, SARS was a dry run for us in Toronto and the other places in the world that it affected (Taiwan, Hong Kong, Singapore); one that helped us prepare in advance and will help us cope with COVID-19. But what did I personally learn from my SARS experience?

First, I learned that accurate information in these kinds of situations is hard to come by. We heard lots of rumors from people all over the world. But when I found that it was very difficult for me to figure out exactly what was going on in my own hospital (eg, who was in contact with people who fell ill or went into quarantine, how patients were faring), I realized that figuring out what was happening half way around the world from news reports was near impossible. I learned to wait for official announcements.

Second, I learned that talking to my colleagues was both therapeutic—providing emotional support and an outlet for feelings—and anxiety provoking when we overreacted to rumors.

Third, I learned that, like others, I was susceptible to exhibiting obsessive behaviors in an attempt to establish control over uncertainty. Constantly washing my hands, checking my temperature, and seeking reassuring facts from others only worked to calm me for a few minutes. And then I felt the need to do it again. This time I find myself checking my twitter account constantly; half afraid I will see something frightening, half looking for good news from people I trust. I now recognize this behavior and it helps me contain it.

Fourth, I learned that events that occurred remotely had much less effect on everyone than those that occurred close by. Having two people I knew get SARS, and then learning they recovered was perhaps the most meaningful event for me during the entire episode.

Finally, I learned that in the end I and the people I care about survived—nothing bad happened to us. The world did not end after SARS. It took me about a year, including some time with a terrific psychiatrist, to realize I was safe after all. And that realization is what I am most hanging on to today.

Acknowledgments

Sanjay Saint (University of Michigan), Christopher Booth (Queens University), and Sagar Rohailla (University of Toronto) provided comments on an earlier draft. None were compensated for doing so.

In 1996, internists Robert Wachter, MD, and Lee Goldman, MD, MPH, coined the term “hospitalist” and predicted an “emerging role in the American health care system.”¹ Pediatrics was not far behind: In 1999, Dr Wachter joined Paul Bellet, MD, in authoring an article describing the movement within pediatrics.² An accompanying editorial, coauthored by a pediatric hospitalist and an office-based practitioner, attempted to answer which was “better” for a hospitalized child: A practitioner who knew the child and family or a hospitalist who might be more knowledgeable about the disease, its inpatient management, and how to get things done in the hospital?³ The authors could not answer which model was better for an individual child with an invested primary pediatrician, but concluded that hospitalists have the potential to improve care for all children in the hospital—the future promise of Pediatric Hospital Medicine (PHM). This article traces the growth of PHM from 1996 to the present, highlighting developments that fueled the hospital movement in general and PHM in particular (Table).

In the 7 years after the article by Drs Wachter and Goldman, a series of regulations fostered the adoption of hospitalists in teaching hospitals. The first was the reissuance in 1997 of Intermediary Letter 372, which specifies the requirements for attending physicians to bill Medicare.⁴ The common practice of jotting “agree with above” and cosigning resident notes was no longer sufficient: Attendings had to document that they personally provided services to patients beyond those of residents. As a demonstration of enforcement, records at the Hospital of the University of Pennsylvania in Philadelphia were audited, and a bill for $30 million for overpayments and penalties was issued.⁴ Teaching hospitals took notice and instituted mechanisms to assure compliance with IL-372, not limited to patients insured by Medicare. The obvious effect on faculty was the requirement of considerably more time and involvement in direct patient care.

Later in the 1990s, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new direction termed the Outcome Project, which led to two novel trainee competency domains: practice-based improvement and systems-based practice.⁵ The focus on quality improvement, patient safety, and systems was reinforced by two Institute of Medicine publications, To Err Is Human: Building a Safer Health System⁶ and Crossing the Quality Chasm: A New Health Care System for the 21st Century.⁷ Hospitalists had the opportunity to impact both patient care and the education of learners in two ways: Directly, by more actively participating in and closely supervising clinical care (per IL-372) and, indirectly, by improving hospital systems.

In 2003, the ACGME extended work hour restrictions implemented in New York State to the national level.⁸ The new requirements were intended to improve patient safety and increase trainee supervision, but also had the effect of reducing trainees’ clinical experience. While responses of teaching institutions varied, training program changes generated an increased role for hospitalists.⁹

These changes occurred on a backdrop of changing models of healthcare payment that provided incentive to shorten length of stay (LOS) and shift care from inpatient to ambulatory settings, which increased the acuity and complexity of hospitalized patients. The pressure to increase efficiency and decrease LOS affected faculty, residents, and practitioners in the community. Managing care of inpatients from a distance became more difficult; rounding more than once a day was often required and was disruptive and inefficient, particularly for community practitioners who might have only one or two patients in the hospital. Moreover, the hospital electronic medical record (EMR) became an additional barrier for many practitioners to continue to provide hospital-based care. Systems often differed from those used in their offices, and even when this was not the case, using and maintaining efficiency in the different components of the EMR was difficult. The conversion from paper to electronic documentation and ordering may have contributed to some practitioners relinquishing care of their patients to hospitalists.

The development of PHM was aided by support from three separate organizations, each with a different role: the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA). SHM was founded the year after the article by Drs Wachter and Goldman as the “National Association of Inpatient Physicians.” The name was changed to Society of Hospital Medicine in 2003 to reflect the evolving field of hospital medicine. While the organization is largely comprised of internists, a pediatrician has been on its board since 1998, and a pediatrics committee (now Special Interest Group, SIG) has been in existence since 1999. (Appendix Tables 1a and 1b; Appendix Figures 1a and 1b). In 2005, an SHM task force was formed to define PHM-specific Core Competencies that could serve as a basis for curriculum building and a definition of the field. These inaugural PHM Core Competencies were endorsed by all three societies; published in 2010 in SHM’s flagship journal, the Journal of Hospital Medicine¹⁰; and were recently revised to reflect changes to the field in the past decade.¹¹ SHM has provided valuable opportunities for hospitalists to develop knowledge and skills, particularly in matters related to healthcare operations and leadership, and it serves as a way to keep PHM connected with the larger hospital medicine community.

The AAP initiated its efforts to engage hospitalists in 1998 with the creation of a Provisional Section on Hospital Medicine (SOHM) that became a full section a year later. (Appendix Table 2; Appendix Figure 2) The SOHM listserv^®, created in 2000, became a major vehicle for communication among hospitalists—including individuals who are not members of the SOHM—with more than 4,000 subscribers currently. Of the SOHM achievements noted in the Table, one deserves special mention: In 2006, SOHM formally recognized the large number of hospitalists in community hospitals and established a subsection with Karen Kingry Olson, MD, as inaugural leader. Many of the hospitalists in these sites provide care not only to children on inpatient units but also in areas such as the nursery, delivery room, and emergency department, functioning “like water on pavement—filling all the cracks in the hospital,” as Eric Biondi, MD, MS, puts it.¹² It is a credit to the AAP and the PHM community that individuals from community hospitals have specifically been afforded leadership roles. SOHM membership has grown considerably from around 100 at inception to 2,700 in 2019. Participation in the AAP keeps PHM connected to the larger pediatrics community.

The APA established a Hospital and Inpatient Medicine SIG in 2001, the name of which was changed to Hospital Medicine SIG in 2004 (Appendix Table 3; Appendix Figure 3; Note: There had been an Inpatient General Pediatricians SIG in 1992, before the term hospitalist was coined, but it only met once.) In 2003, APA was the first national pediatrics organization to sponsor a PHM meeting. The meeting attracted 130 registrants and was considered successful enough to warrant another meeting in 2005, this time with SHM and AAP joining as cosponsors. In 2007, the triple-sponsored meetings became annual events, with 1,600 registrants at the 2019 meeting. The success of the initial meeting also caught the attention of APA leadership in another regard: a concern that the name of the organization might interfere with retaining hospitalists in the fold. In 2007, the Ambulatory Pediatric Association became the Academic Pediatric Association.¹³ Being connected with the APA affords PHM a connection to academic generalists and activities central to the APA, such as research and education.

In 2009, PHM leaders within SHM, APA, and AAP held a pivotal strategic planning “roundtable” to discuss the future of the field.¹⁴ A vision statement was developed, serving as a guide to the tasks needed to achieve the vision: “Pediatric hospitalists will transform the delivery of hospital care for children.” Five areas were considered: clinical, quality, research, workforce, and structure. Clinical practice was defined as including both “direct patient care and leadership of the inpatient service.” It was recognized that standardizing, disseminating, and increasing knowledge to improve clinical care was important, but so, too, was taking on leadership roles to improve systems and extend into areas such as sedation. Quality improvement was identified as the measure by which the value of PHM would be assessed. To further efforts in this area, a PHM Quality Improvement (QI) Collaborative work group was created. Research was clearly a necessary component to establish and advance the field. The Children’s Hospital Association had launched the Pediatric Health Information System (PHIS) database in 1993, and PHIS began to flourish as a research database when Samir Shah, MD, MSCE, and Matt Hall, PhD, headed the Research Groups in 2007. Discussions to form an independent research network began in 2001, and, in 2002, the Pediatric Research in Inpatient Settings network (PRIS) was launched, led by Christopher Landrigan, MD, MPH.¹⁵ The APA provided organization support in 2006, but a redesign was considered necessary to further move the research initiative forward.¹⁵ A Research Leadership Task Force was created, resulting in a new PRIS Network Executive Council, chaired by Rajendu Srivastava, MD, MPH, until 2016, when Karen Wilson, MD, MPH, became chair. Clinical and workforce issues focused on the need to supplement residency training with added skills and knowledge to practice as a pediatric hospitalist. An Education Task Force was created, charged with developing “an educational plan supporting the PHM Core Competencies and addressing hospitalist training needs, including the role as formal educators.” The task force was headed by Mary Ottolini, MD, MPH, MEd, who was aided by Jennifer Maniscalco, MD, MPH, MAcM. Regarding structure of PHM, the decision was made not to develop an independent society but to continue to function within and benefit from the resources of SHM, AAP, and APA, with a Joint Council on Pediatric Hospital Medicine (JCPHM). Established in 2011, the JCPHM included representatives of the AAP, APA, SHM, PRIS, VIP, community hospitals, and the Education Task Force. Erin Stucky Fisher, MD, MHM, served as the first chair. The JCPHM was replaced in the fall of 2016 by a Consortium on PHM, which consists of the chairs and chair elects of the AAP SOHM, the APA Hospital Medicine SIG, and the SHM pediatrics committee. The leadership rotates annually among the three organizations.

The American Board of Pediatrics (ABP) recognized the growing field of PHM and, through its foundation, commissioned a series of studies, the first of which was published in 2006 entitled “Hospitalists in children’s hospitals: What we know now and what we need to know.”¹⁶ It was not clear whether the PHM community would pursue subspecialty certification. The leaders of the 2009 “roundtable” meeting commissioned a Strategic Planning Committee (STP) led by Christopher Maloney, MD, PhD, and Suzanne Swanson Mendez, MD, to evaluate the best course of action: traditional ABP subspecialty certification, hospital medicine residency track (with or without additional fellowship), Recognition of Focused Practice (as implemented by the American Board of Internal Medicine and American Board of Family Medicine), mandatory mentorship program, or status quo with option for specialized training. There was considerable discussion of the alternatives in the PHM community. In 2012, the STP shared the results of Strengths-Weaknesses-Opportunities-Threats analyses—but did not issue a recommendation.¹⁷ The following year, a National PHM Leaders Conference was held to consider the various options. Participants concluded that the best path forward was to pursue subspecialty certification with a requirement for 2 years of fellowship (after a time-limited period for practice pathway eligibility). Two years of fellowship was a departure from the ABP’s standard 3 years, but seemed acceptable based on the expectation that the research component would be integrated with clinical activities (eg, QI), rather than separate bench research. The ABP Initiative on Subspecialty Clinical Training and Certification had recommended flexibility in the duration of fellowships,¹⁸ and PHM became the first discipline to take advantage of such flexibility. Following an 18-month review of multiple considerations, the ABP concluded that “children will be better served by establishing the discipline as a new subspecialty.”¹⁹

The decision to pursue subspecialty certification was not unanimously embraced by the PHM community, with particular concerns expressed regarding the impact on Med-Peds hospitalists and the future in community hospitals. These were considered by the individuals writing the formal proposal to the ABP, but have not been resolved. Moreover, criteria for eligibility for the certifying examination under the Practice Pathway (“grandparenting”) evoked controversy,²⁰ addressed by the ABP. ²¹ The first subspecialty certifying examination was ultimately administered to ~1,500 pediatric hospitalists in 2019.

It is clear that PHM has established itself as a field, with networks for research and quality improvement, more than 50 fellowship programs, divisions in prestigious departments of pediatrics and children’s hospitals, devoted journals and textbooks, and a well-attended annual meeting. PHM has set standards for the core competencies in PHM,^{11, 12} for pediatric hospitalist programs,^{22, 23} for coordinating the hospital care of children,^{24, 25} for the curricular framework of fellowships,²⁶ and for the Entrustable Professional Activities expected of a hospitalist.²⁷ The vision for the future is that continued efforts in research, quality and systems improvement, and clinical care will, in fact, result in significant benefits for all hospitalized children. Such was the promise of PHM in the 1990s and remains so in 2019.

Acknowledgments

For prompting the project: Rachel Marek. For additions, corrections, and confirmations: David Alexander, Niccole Alexander, Paul Bellet, David Bertoch, Douglas Carlson, Laura Degnon, Kimberly Durham, Barrett Fromme, Sandy Gage, Matthew Garber, Karen Jerardi, Christopher Landrigan, Gail McGuinness, Jennifer Maniscalco, Sandy Melzer, Vineeta Mittal, Karen Kingry Olson, Mary Ottolini, Jack Percelay, Kris Rehm, Michael Ruhlen, Samir Shah, Suzanne Woods, and David Zipes.

Disclosures

The authors have nothing to disclose.

In 1996, internists Robert Wachter, MD, and Lee Goldman, MD, MPH, coined the term “hospitalist” and predicted an “emerging role in the American health care system.”¹ Pediatrics was not far behind: In 1999, Dr Wachter joined Paul Bellet, MD, in authoring an article describing the movement within pediatrics.² An accompanying editorial, coauthored by a pediatric hospitalist and an office-based practitioner, attempted to answer which was “better” for a hospitalized child: A practitioner who knew the child and family or a hospitalist who might be more knowledgeable about the disease, its inpatient management, and how to get things done in the hospital?³ The authors could not answer which model was better for an individual child with an invested primary pediatrician, but concluded that hospitalists have the potential to improve care for all children in the hospital—the future promise of Pediatric Hospital Medicine (PHM). This article traces the growth of PHM from 1996 to the present, highlighting developments that fueled the hospital movement in general and PHM in particular (Table).

In the 7 years after the article by Drs Wachter and Goldman, a series of regulations fostered the adoption of hospitalists in teaching hospitals. The first was the reissuance in 1997 of Intermediary Letter 372, which specifies the requirements for attending physicians to bill Medicare.⁴ The common practice of jotting “agree with above” and cosigning resident notes was no longer sufficient: Attendings had to document that they personally provided services to patients beyond those of residents. As a demonstration of enforcement, records at the Hospital of the University of Pennsylvania in Philadelphia were audited, and a bill for $30 million for overpayments and penalties was issued.⁴ Teaching hospitals took notice and instituted mechanisms to assure compliance with IL-372, not limited to patients insured by Medicare. The obvious effect on faculty was the requirement of considerably more time and involvement in direct patient care.

Later in the 1990s, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new direction termed the Outcome Project, which led to two novel trainee competency domains: practice-based improvement and systems-based practice.⁵ The focus on quality improvement, patient safety, and systems was reinforced by two Institute of Medicine publications, To Err Is Human: Building a Safer Health System⁶ and Crossing the Quality Chasm: A New Health Care System for the 21st Century.⁷ Hospitalists had the opportunity to impact both patient care and the education of learners in two ways: Directly, by more actively participating in and closely supervising clinical care (per IL-372) and, indirectly, by improving hospital systems.

In 2003, the ACGME extended work hour restrictions implemented in New York State to the national level.⁸ The new requirements were intended to improve patient safety and increase trainee supervision, but also had the effect of reducing trainees’ clinical experience. While responses of teaching institutions varied, training program changes generated an increased role for hospitalists.⁹

These changes occurred on a backdrop of changing models of healthcare payment that provided incentive to shorten length of stay (LOS) and shift care from inpatient to ambulatory settings, which increased the acuity and complexity of hospitalized patients. The pressure to increase efficiency and decrease LOS affected faculty, residents, and practitioners in the community. Managing care of inpatients from a distance became more difficult; rounding more than once a day was often required and was disruptive and inefficient, particularly for community practitioners who might have only one or two patients in the hospital. Moreover, the hospital electronic medical record (EMR) became an additional barrier for many practitioners to continue to provide hospital-based care. Systems often differed from those used in their offices, and even when this was not the case, using and maintaining efficiency in the different components of the EMR was difficult. The conversion from paper to electronic documentation and ordering may have contributed to some practitioners relinquishing care of their patients to hospitalists.

The development of PHM was aided by support from three separate organizations, each with a different role: the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA). SHM was founded the year after the article by Drs Wachter and Goldman as the “National Association of Inpatient Physicians.” The name was changed to Society of Hospital Medicine in 2003 to reflect the evolving field of hospital medicine. While the organization is largely comprised of internists, a pediatrician has been on its board since 1998, and a pediatrics committee (now Special Interest Group, SIG) has been in existence since 1999. (Appendix Tables 1a and 1b; Appendix Figures 1a and 1b). In 2005, an SHM task force was formed to define PHM-specific Core Competencies that could serve as a basis for curriculum building and a definition of the field. These inaugural PHM Core Competencies were endorsed by all three societies; published in 2010 in SHM’s flagship journal, the Journal of Hospital Medicine¹⁰; and were recently revised to reflect changes to the field in the past decade.¹¹ SHM has provided valuable opportunities for hospitalists to develop knowledge and skills, particularly in matters related to healthcare operations and leadership, and it serves as a way to keep PHM connected with the larger hospital medicine community.

The AAP initiated its efforts to engage hospitalists in 1998 with the creation of a Provisional Section on Hospital Medicine (SOHM) that became a full section a year later. (Appendix Table 2; Appendix Figure 2) The SOHM listserv^®, created in 2000, became a major vehicle for communication among hospitalists—including individuals who are not members of the SOHM—with more than 4,000 subscribers currently. Of the SOHM achievements noted in the Table, one deserves special mention: In 2006, SOHM formally recognized the large number of hospitalists in community hospitals and established a subsection with Karen Kingry Olson, MD, as inaugural leader. Many of the hospitalists in these sites provide care not only to children on inpatient units but also in areas such as the nursery, delivery room, and emergency department, functioning “like water on pavement—filling all the cracks in the hospital,” as Eric Biondi, MD, MS, puts it.¹² It is a credit to the AAP and the PHM community that individuals from community hospitals have specifically been afforded leadership roles. SOHM membership has grown considerably from around 100 at inception to 2,700 in 2019. Participation in the AAP keeps PHM connected to the larger pediatrics community.

The APA established a Hospital and Inpatient Medicine SIG in 2001, the name of which was changed to Hospital Medicine SIG in 2004 (Appendix Table 3; Appendix Figure 3; Note: There had been an Inpatient General Pediatricians SIG in 1992, before the term hospitalist was coined, but it only met once.) In 2003, APA was the first national pediatrics organization to sponsor a PHM meeting. The meeting attracted 130 registrants and was considered successful enough to warrant another meeting in 2005, this time with SHM and AAP joining as cosponsors. In 2007, the triple-sponsored meetings became annual events, with 1,600 registrants at the 2019 meeting. The success of the initial meeting also caught the attention of APA leadership in another regard: a concern that the name of the organization might interfere with retaining hospitalists in the fold. In 2007, the Ambulatory Pediatric Association became the Academic Pediatric Association.¹³ Being connected with the APA affords PHM a connection to academic generalists and activities central to the APA, such as research and education.

In 2009, PHM leaders within SHM, APA, and AAP held a pivotal strategic planning “roundtable” to discuss the future of the field.¹⁴ A vision statement was developed, serving as a guide to the tasks needed to achieve the vision: “Pediatric hospitalists will transform the delivery of hospital care for children.” Five areas were considered: clinical, quality, research, workforce, and structure. Clinical practice was defined as including both “direct patient care and leadership of the inpatient service.” It was recognized that standardizing, disseminating, and increasing knowledge to improve clinical care was important, but so, too, was taking on leadership roles to improve systems and extend into areas such as sedation. Quality improvement was identified as the measure by which the value of PHM would be assessed. To further efforts in this area, a PHM Quality Improvement (QI) Collaborative work group was created. Research was clearly a necessary component to establish and advance the field. The Children’s Hospital Association had launched the Pediatric Health Information System (PHIS) database in 1993, and PHIS began to flourish as a research database when Samir Shah, MD, MSCE, and Matt Hall, PhD, headed the Research Groups in 2007. Discussions to form an independent research network began in 2001, and, in 2002, the Pediatric Research in Inpatient Settings network (PRIS) was launched, led by Christopher Landrigan, MD, MPH.¹⁵ The APA provided organization support in 2006, but a redesign was considered necessary to further move the research initiative forward.¹⁵ A Research Leadership Task Force was created, resulting in a new PRIS Network Executive Council, chaired by Rajendu Srivastava, MD, MPH, until 2016, when Karen Wilson, MD, MPH, became chair. Clinical and workforce issues focused on the need to supplement residency training with added skills and knowledge to practice as a pediatric hospitalist. An Education Task Force was created, charged with developing “an educational plan supporting the PHM Core Competencies and addressing hospitalist training needs, including the role as formal educators.” The task force was headed by Mary Ottolini, MD, MPH, MEd, who was aided by Jennifer Maniscalco, MD, MPH, MAcM. Regarding structure of PHM, the decision was made not to develop an independent society but to continue to function within and benefit from the resources of SHM, AAP, and APA, with a Joint Council on Pediatric Hospital Medicine (JCPHM). Established in 2011, the JCPHM included representatives of the AAP, APA, SHM, PRIS, VIP, community hospitals, and the Education Task Force. Erin Stucky Fisher, MD, MHM, served as the first chair. The JCPHM was replaced in the fall of 2016 by a Consortium on PHM, which consists of the chairs and chair elects of the AAP SOHM, the APA Hospital Medicine SIG, and the SHM pediatrics committee. The leadership rotates annually among the three organizations.

The American Board of Pediatrics (ABP) recognized the growing field of PHM and, through its foundation, commissioned a series of studies, the first of which was published in 2006 entitled “Hospitalists in children’s hospitals: What we know now and what we need to know.”¹⁶ It was not clear whether the PHM community would pursue subspecialty certification. The leaders of the 2009 “roundtable” meeting commissioned a Strategic Planning Committee (STP) led by Christopher Maloney, MD, PhD, and Suzanne Swanson Mendez, MD, to evaluate the best course of action: traditional ABP subspecialty certification, hospital medicine residency track (with or without additional fellowship), Recognition of Focused Practice (as implemented by the American Board of Internal Medicine and American Board of Family Medicine), mandatory mentorship program, or status quo with option for specialized training. There was considerable discussion of the alternatives in the PHM community. In 2012, the STP shared the results of Strengths-Weaknesses-Opportunities-Threats analyses—but did not issue a recommendation.¹⁷ The following year, a National PHM Leaders Conference was held to consider the various options. Participants concluded that the best path forward was to pursue subspecialty certification with a requirement for 2 years of fellowship (after a time-limited period for practice pathway eligibility). Two years of fellowship was a departure from the ABP’s standard 3 years, but seemed acceptable based on the expectation that the research component would be integrated with clinical activities (eg, QI), rather than separate bench research. The ABP Initiative on Subspecialty Clinical Training and Certification had recommended flexibility in the duration of fellowships,¹⁸ and PHM became the first discipline to take advantage of such flexibility. Following an 18-month review of multiple considerations, the ABP concluded that “children will be better served by establishing the discipline as a new subspecialty.”¹⁹

The decision to pursue subspecialty certification was not unanimously embraced by the PHM community, with particular concerns expressed regarding the impact on Med-Peds hospitalists and the future in community hospitals. These were considered by the individuals writing the formal proposal to the ABP, but have not been resolved. Moreover, criteria for eligibility for the certifying examination under the Practice Pathway (“grandparenting”) evoked controversy,²⁰ addressed by the ABP. ²¹ The first subspecialty certifying examination was ultimately administered to ~1,500 pediatric hospitalists in 2019.

It is clear that PHM has established itself as a field, with networks for research and quality improvement, more than 50 fellowship programs, divisions in prestigious departments of pediatrics and children’s hospitals, devoted journals and textbooks, and a well-attended annual meeting. PHM has set standards for the core competencies in PHM,^{11, 12} for pediatric hospitalist programs,^{22, 23} for coordinating the hospital care of children,^{24, 25} for the curricular framework of fellowships,²⁶ and for the Entrustable Professional Activities expected of a hospitalist.²⁷ The vision for the future is that continued efforts in research, quality and systems improvement, and clinical care will, in fact, result in significant benefits for all hospitalized children. Such was the promise of PHM in the 1990s and remains so in 2019.

Acknowledgments

For prompting the project: Rachel Marek. For additions, corrections, and confirmations: David Alexander, Niccole Alexander, Paul Bellet, David Bertoch, Douglas Carlson, Laura Degnon, Kimberly Durham, Barrett Fromme, Sandy Gage, Matthew Garber, Karen Jerardi, Christopher Landrigan, Gail McGuinness, Jennifer Maniscalco, Sandy Melzer, Vineeta Mittal, Karen Kingry Olson, Mary Ottolini, Jack Percelay, Kris Rehm, Michael Ruhlen, Samir Shah, Suzanne Woods, and David Zipes.

Disclosures

The authors have nothing to disclose.

In 1996, internists Robert Wachter, MD, and Lee Goldman, MD, MPH, coined the term “hospitalist” and predicted an “emerging role in the American health care system.”¹ Pediatrics was not far behind: In 1999, Dr Wachter joined Paul Bellet, MD, in authoring an article describing the movement within pediatrics.² An accompanying editorial, coauthored by a pediatric hospitalist and an office-based practitioner, attempted to answer which was “better” for a hospitalized child: A practitioner who knew the child and family or a hospitalist who might be more knowledgeable about the disease, its inpatient management, and how to get things done in the hospital?³ The authors could not answer which model was better for an individual child with an invested primary pediatrician, but concluded that hospitalists have the potential to improve care for all children in the hospital—the future promise of Pediatric Hospital Medicine (PHM). This article traces the growth of PHM from 1996 to the present, highlighting developments that fueled the hospital movement in general and PHM in particular (Table).

In the 7 years after the article by Drs Wachter and Goldman, a series of regulations fostered the adoption of hospitalists in teaching hospitals. The first was the reissuance in 1997 of Intermediary Letter 372, which specifies the requirements for attending physicians to bill Medicare.⁴ The common practice of jotting “agree with above” and cosigning resident notes was no longer sufficient: Attendings had to document that they personally provided services to patients beyond those of residents. As a demonstration of enforcement, records at the Hospital of the University of Pennsylvania in Philadelphia were audited, and a bill for $30 million for overpayments and penalties was issued.⁴ Teaching hospitals took notice and instituted mechanisms to assure compliance with IL-372, not limited to patients insured by Medicare. The obvious effect on faculty was the requirement of considerably more time and involvement in direct patient care.

Later in the 1990s, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new direction termed the Outcome Project, which led to two novel trainee competency domains: practice-based improvement and systems-based practice.⁵ The focus on quality improvement, patient safety, and systems was reinforced by two Institute of Medicine publications, To Err Is Human: Building a Safer Health System⁶ and Crossing the Quality Chasm: A New Health Care System for the 21st Century.⁷ Hospitalists had the opportunity to impact both patient care and the education of learners in two ways: Directly, by more actively participating in and closely supervising clinical care (per IL-372) and, indirectly, by improving hospital systems.

In 2003, the ACGME extended work hour restrictions implemented in New York State to the national level.⁸ The new requirements were intended to improve patient safety and increase trainee supervision, but also had the effect of reducing trainees’ clinical experience. While responses of teaching institutions varied, training program changes generated an increased role for hospitalists.⁹

These changes occurred on a backdrop of changing models of healthcare payment that provided incentive to shorten length of stay (LOS) and shift care from inpatient to ambulatory settings, which increased the acuity and complexity of hospitalized patients. The pressure to increase efficiency and decrease LOS affected faculty, residents, and practitioners in the community. Managing care of inpatients from a distance became more difficult; rounding more than once a day was often required and was disruptive and inefficient, particularly for community practitioners who might have only one or two patients in the hospital. Moreover, the hospital electronic medical record (EMR) became an additional barrier for many practitioners to continue to provide hospital-based care. Systems often differed from those used in their offices, and even when this was not the case, using and maintaining efficiency in the different components of the EMR was difficult. The conversion from paper to electronic documentation and ordering may have contributed to some practitioners relinquishing care of their patients to hospitalists.

The development of PHM was aided by support from three separate organizations, each with a different role: the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA). SHM was founded the year after the article by Drs Wachter and Goldman as the “National Association of Inpatient Physicians.” The name was changed to Society of Hospital Medicine in 2003 to reflect the evolving field of hospital medicine. While the organization is largely comprised of internists, a pediatrician has been on its board since 1998, and a pediatrics committee (now Special Interest Group, SIG) has been in existence since 1999. (Appendix Tables 1a and 1b; Appendix Figures 1a and 1b). In 2005, an SHM task force was formed to define PHM-specific Core Competencies that could serve as a basis for curriculum building and a definition of the field. These inaugural PHM Core Competencies were endorsed by all three societies; published in 2010 in SHM’s flagship journal, the Journal of Hospital Medicine¹⁰; and were recently revised to reflect changes to the field in the past decade.¹¹ SHM has provided valuable opportunities for hospitalists to develop knowledge and skills, particularly in matters related to healthcare operations and leadership, and it serves as a way to keep PHM connected with the larger hospital medicine community.

The AAP initiated its efforts to engage hospitalists in 1998 with the creation of a Provisional Section on Hospital Medicine (SOHM) that became a full section a year later. (Appendix Table 2; Appendix Figure 2) The SOHM listserv^®, created in 2000, became a major vehicle for communication among hospitalists—including individuals who are not members of the SOHM—with more than 4,000 subscribers currently. Of the SOHM achievements noted in the Table, one deserves special mention: In 2006, SOHM formally recognized the large number of hospitalists in community hospitals and established a subsection with Karen Kingry Olson, MD, as inaugural leader. Many of the hospitalists in these sites provide care not only to children on inpatient units but also in areas such as the nursery, delivery room, and emergency department, functioning “like water on pavement—filling all the cracks in the hospital,” as Eric Biondi, MD, MS, puts it.¹² It is a credit to the AAP and the PHM community that individuals from community hospitals have specifically been afforded leadership roles. SOHM membership has grown considerably from around 100 at inception to 2,700 in 2019. Participation in the AAP keeps PHM connected to the larger pediatrics community.

The APA established a Hospital and Inpatient Medicine SIG in 2001, the name of which was changed to Hospital Medicine SIG in 2004 (Appendix Table 3; Appendix Figure 3; Note: There had been an Inpatient General Pediatricians SIG in 1992, before the term hospitalist was coined, but it only met once.) In 2003, APA was the first national pediatrics organization to sponsor a PHM meeting. The meeting attracted 130 registrants and was considered successful enough to warrant another meeting in 2005, this time with SHM and AAP joining as cosponsors. In 2007, the triple-sponsored meetings became annual events, with 1,600 registrants at the 2019 meeting. The success of the initial meeting also caught the attention of APA leadership in another regard: a concern that the name of the organization might interfere with retaining hospitalists in the fold. In 2007, the Ambulatory Pediatric Association became the Academic Pediatric Association.¹³ Being connected with the APA affords PHM a connection to academic generalists and activities central to the APA, such as research and education.

In 2009, PHM leaders within SHM, APA, and AAP held a pivotal strategic planning “roundtable” to discuss the future of the field.¹⁴ A vision statement was developed, serving as a guide to the tasks needed to achieve the vision: “Pediatric hospitalists will transform the delivery of hospital care for children.” Five areas were considered: clinical, quality, research, workforce, and structure. Clinical practice was defined as including both “direct patient care and leadership of the inpatient service.” It was recognized that standardizing, disseminating, and increasing knowledge to improve clinical care was important, but so, too, was taking on leadership roles to improve systems and extend into areas such as sedation. Quality improvement was identified as the measure by which the value of PHM would be assessed. To further efforts in this area, a PHM Quality Improvement (QI) Collaborative work group was created. Research was clearly a necessary component to establish and advance the field. The Children’s Hospital Association had launched the Pediatric Health Information System (PHIS) database in 1993, and PHIS began to flourish as a research database when Samir Shah, MD, MSCE, and Matt Hall, PhD, headed the Research Groups in 2007. Discussions to form an independent research network began in 2001, and, in 2002, the Pediatric Research in Inpatient Settings network (PRIS) was launched, led by Christopher Landrigan, MD, MPH.¹⁵ The APA provided organization support in 2006, but a redesign was considered necessary to further move the research initiative forward.¹⁵ A Research Leadership Task Force was created, resulting in a new PRIS Network Executive Council, chaired by Rajendu Srivastava, MD, MPH, until 2016, when Karen Wilson, MD, MPH, became chair. Clinical and workforce issues focused on the need to supplement residency training with added skills and knowledge to practice as a pediatric hospitalist. An Education Task Force was created, charged with developing “an educational plan supporting the PHM Core Competencies and addressing hospitalist training needs, including the role as formal educators.” The task force was headed by Mary Ottolini, MD, MPH, MEd, who was aided by Jennifer Maniscalco, MD, MPH, MAcM. Regarding structure of PHM, the decision was made not to develop an independent society but to continue to function within and benefit from the resources of SHM, AAP, and APA, with a Joint Council on Pediatric Hospital Medicine (JCPHM). Established in 2011, the JCPHM included representatives of the AAP, APA, SHM, PRIS, VIP, community hospitals, and the Education Task Force. Erin Stucky Fisher, MD, MHM, served as the first chair. The JCPHM was replaced in the fall of 2016 by a Consortium on PHM, which consists of the chairs and chair elects of the AAP SOHM, the APA Hospital Medicine SIG, and the SHM pediatrics committee. The leadership rotates annually among the three organizations.

The American Board of Pediatrics (ABP) recognized the growing field of PHM and, through its foundation, commissioned a series of studies, the first of which was published in 2006 entitled “Hospitalists in children’s hospitals: What we know now and what we need to know.”¹⁶ It was not clear whether the PHM community would pursue subspecialty certification. The leaders of the 2009 “roundtable” meeting commissioned a Strategic Planning Committee (STP) led by Christopher Maloney, MD, PhD, and Suzanne Swanson Mendez, MD, to evaluate the best course of action: traditional ABP subspecialty certification, hospital medicine residency track (with or without additional fellowship), Recognition of Focused Practice (as implemented by the American Board of Internal Medicine and American Board of Family Medicine), mandatory mentorship program, or status quo with option for specialized training. There was considerable discussion of the alternatives in the PHM community. In 2012, the STP shared the results of Strengths-Weaknesses-Opportunities-Threats analyses—but did not issue a recommendation.¹⁷ The following year, a National PHM Leaders Conference was held to consider the various options. Participants concluded that the best path forward was to pursue subspecialty certification with a requirement for 2 years of fellowship (after a time-limited period for practice pathway eligibility). Two years of fellowship was a departure from the ABP’s standard 3 years, but seemed acceptable based on the expectation that the research component would be integrated with clinical activities (eg, QI), rather than separate bench research. The ABP Initiative on Subspecialty Clinical Training and Certification had recommended flexibility in the duration of fellowships,¹⁸ and PHM became the first discipline to take advantage of such flexibility. Following an 18-month review of multiple considerations, the ABP concluded that “children will be better served by establishing the discipline as a new subspecialty.”¹⁹

The decision to pursue subspecialty certification was not unanimously embraced by the PHM community, with particular concerns expressed regarding the impact on Med-Peds hospitalists and the future in community hospitals. These were considered by the individuals writing the formal proposal to the ABP, but have not been resolved. Moreover, criteria for eligibility for the certifying examination under the Practice Pathway (“grandparenting”) evoked controversy,²⁰ addressed by the ABP. ²¹ The first subspecialty certifying examination was ultimately administered to ~1,500 pediatric hospitalists in 2019.

It is clear that PHM has established itself as a field, with networks for research and quality improvement, more than 50 fellowship programs, divisions in prestigious departments of pediatrics and children’s hospitals, devoted journals and textbooks, and a well-attended annual meeting. PHM has set standards for the core competencies in PHM,^{11, 12} for pediatric hospitalist programs,^{22, 23} for coordinating the hospital care of children,^{24, 25} for the curricular framework of fellowships,²⁶ and for the Entrustable Professional Activities expected of a hospitalist.²⁷ The vision for the future is that continued efforts in research, quality and systems improvement, and clinical care will, in fact, result in significant benefits for all hospitalized children. Such was the promise of PHM in the 1990s and remains so in 2019.

Acknowledgments

For prompting the project: Rachel Marek. For additions, corrections, and confirmations: David Alexander, Niccole Alexander, Paul Bellet, David Bertoch, Douglas Carlson, Laura Degnon, Kimberly Durham, Barrett Fromme, Sandy Gage, Matthew Garber, Karen Jerardi, Christopher Landrigan, Gail McGuinness, Jennifer Maniscalco, Sandy Melzer, Vineeta Mittal, Karen Kingry Olson, Mary Ottolini, Jack Percelay, Kris Rehm, Michael Ruhlen, Samir Shah, Suzanne Woods, and David Zipes.

Disclosures

The authors have nothing to disclose.