Perspectives in Hospital Medicine

The recent closure of Hahnemann University Hospital, a 500-bed teaching hospital in downtown Philadelphia, Pennsylvania, offers a case study of a new form of for-profit business involvement in academic medicine —private equity investment. Though the closure of this 171-year-old institution is the result of multiple factors affecting the hospital’s financial health over decades and may not have been avoidable, the hospital’s final years in the hands of a private equity firm led to a closure process that was chaotic, uncoordinated, and fundamentally not aligned with the needs of the patients and trainees that make up the core constituents of a teaching hospital. This hospital’s story involves a concerning trend that underscores the dissonance in mission of private equity and academic medicine. In an era of competition and market consolidation, other teaching hospitals may be forced to close under similar circumstances in the future, making it vital that the medical and academic communities be aware of these discordant missions to guide policy-making efforts and ensure that the needs of patients and trainees take priority in transition planning rather than the needs of investors.

Tracing the hospital’s history, much of its financial troubles began over 20 years ago. In 1993, the Allegheny Health, Education, and Research Foundation (AHERF), a nonprofit Pittsburgh-based hospital and physician practice organization, acquired Hahnemann Medical College. Forming the MCP-Hahnemann Medical School, AHERF merged the institution with another acquisition, Medical College of Pennsylvania (MCP),¹ formerly known as the Woman’s Medical College of Pennsylvania, one of the first American medical schools devoted to exclusively training female physicians.^1,2 This was part of AHERF’s aggressive growth strategy at the time and resulted in the acquisition of 14 hospitals and more than 300 Philadelphia-area primary care physician practices by 1998. This caused about $1.3 billion of debt and over $1 million in losses per day, which led AHERF to file for bankruptcy that year,² the country’s largest nonprofit healthcare bankruptcy at the time.¹ That same year, Tenet Healthcare Corporation, a for-profit healthcare company, bought AHERF’s assets in the Philadelphia region from bankruptcy for $345 million, acquiring eight hospitals, as well as all of AHREF’s physician practices.² Ultimately, Tenet sold or closed six of the acquired hospitals by 2007, leaving just Hahnemann and St. Christopher’s Hospital for Children,³ while Drexel University, a private, nonprofit university, came forward to salvage AHERF’s educational programs, creating the Drexel University College of Medicine.² Under the ownership of Tenet, Hahnemann’s financial health declined as its patient population included a growing proportion of those utilizing Medicare, Medicaid, and charity care, which resulted in a negative operating profit margin annually for the final 14 years under Tenet.^3,4 In this setting, American Academic Health System, LLC (AAHS) stepped in to purchase Hahnemann and St. Christopher’s from Tenet and, eventually, chose to close Hahnemann.⁴

That Hahnemann found itself in the hands of a private equity firm was not surprising. Such investment firms’ acquisitions of hospitals and physician practices have become increasingly more common, with the number of these types of deals increasing by 48% and reaching a value of $42.6 billion from 2010 to 2017.⁵ While for-profit hospitals have been shown to have higher mortality⁶ and lower patient satisfaction⁷ than nonprofit hospitals, the relatively new and growing trend of private equity investment in healthcare has not been rigorously evaluated. By nature, these firms use investor capital to acquire assets with the goal of increasing their value and selling them off at a profit after about 3-7 years.⁵ Thus, healthcare services provided by private equity–owned facilities are valued and supported based on their profitability. Low-profit services, such as primary care and psychiatry, are minimized while more profitable services, such as same-day surgery, are maximized.⁵ In addition, given that for-profit hospitals tend to invest less in charity care⁸ and population health⁹ as compared with nonprofit institutions, private equity–owned hospitals likely follow suit, in contrast to the humanistic values of academic medicine. Ultimately, Hahnemann’s decades-long financial troubles set the stage for a buyout by private equity investors. But this transaction was the death knell for this teaching hospital and eventually proved to be a disadvantage for the community it served.

Purchasing Hahnemann and St Christopher’s from Tenet in early 2018 for $170 million, AAHS—an affiliate of the private equity firm, Paladin Healthcare Capital, LLC, led by investment banker Joel Freedman—entered the Philadelphia healthcare market in partnership with Chicago-based healthcare real estate private equity firm, Harrison Street Real Estate Capital, LLC.⁴ Paladin had previously invested in smaller hospitals serving underserved communities,⁴ and as it began its venture with this large teaching hospital, Paladin’s president, Barry Wolfman, stated that the company’s goal was “to return [Hahnemann] to its rightful place in the landscape of healthcare.”³ However, given the real estate firm’s involvement in the deal and the permissive tier of zoning for Hahnemann’s real estate,1⁰ there were suspicions that the purchase of the hospital was a means to acquire and develop the valuable Center City real estate rather than to serve the community.³

Within months of the hospital purchase, AAHS‘s Philadelphia venture proved difficult. Four CEOs came and went as time passed, with some holding their position for only a couple of months.1¹ About 175 of Hahnemann’s nurses, support staff, and managers were laid off in April of 2019, but the hospital finances did not improve significantly.1² As it became evident that AAHS planned to close the hospital, efforts were made to prevent the closure. Drexel University filed an unsuccessful lawsuit, claiming that it would be a violation of the academic agreement between the university and hospital.1³ Once AAHS announced plans for hospital closure, the Pennsylvania Secretary of Health, Rachel Levine, MD, wrote to AAHS leadership ordering a “cease and desist” of any action toward hospital closure.¹² Despite this, AAHS began cutting vital hospital services, including trauma and cardiothoracic surgery services, within days of the closure announcement.¹⁴ While there is a state law that a hospital cannot be closed with less than 90 days’ notice, AAHS filed for bankruptcy and shut down Hahnemann’s service to the community in about half that time.¹³ The hospital real estate was separated from the operating businesses and was excluded from the bankruptcy filing,¹⁰ which further cemented suspicions that the involved private equity firms looked to profit off the land once the hospital closed.

The immediate and long-term effects of the closure of Hahnemann University Hospital on healthcare and medical education in Philadelphia are yet to be rigorously measured and evaluated. However, the hasty closure of a large inner-city teaching hospital that served as a healthcare safety net for a largely underserved minority population with 50,000 ED visits per year⁴ is a dangerous disruption to a community. The way that the hospital was closed not only defied regulatory attempts at protecting the community but also defied the values of the healthcare workers working in the hospital. Because AAHS ceased payments to hospital vendors, medical supplies were low during the final weeks at Hahnemann, which didn’t even have enough cups on the wards to provide drinking water for patients.¹⁵ Nurses reported feeling shame as they used scissors to cut wash cloths in half to have enough to wash their patients.¹⁵ The teaching hospital’s humanistic and social capital was being liquidated quickly. Even after Hahnemann’s 570 graduate medical trainees endured the stressful and chaotic process of being displaced and fortunately taken in by other programs,¹⁶ AAHS attempted to auction off Hahnemann’s graduate medical education (GME) slots and their associated government funding to the highest bidder. While a US bankruptcy judge initially approved the sale of those GME slots to a consortium of academic institutions in the Philadelphia area,¹⁷ the Center for Medicare & Medicaid Services (CMS) has appealed that decision, which resulted in a current stay on the transaction.¹⁷ AAHS treating GME trainee positions as assets to be bought and sold is a dangerous precedent to set, especially since it attempts to bypass CMS’s existing regulated process for redistributing the slots.

While time will reveal the effects of the hospital closure, the most concerning element of this story is that the methods of a private equity firm in closing a large inner-city teaching hospital flouted attempts by regulatory agencies acting to preserve the hospital’s mission to the community. The governor of Pennsylvania, Tom Wolf (D), and mayor of Philadelphia, Jim Kenney (D), issued a joint statement chastising the actions of AAHS: “The situation at Hahnemann University Hospital, caused by CEO Joel Freedman and his team of venture capitalists, is an absolute disgrace and shows a greed-driven lack of care for the community.”1⁸ This chaotic situation inspired Philadelphia Councilperson Helen Gym (D) to propose city legislation requiring 180 days’ notice of a hospital closure, bestowing a strong local means of protecting the city’s people from similar healthcare fiascos in the future.¹⁵

At its core, healthcare is a human-to-human interaction with the purpose of improving and maintaining the health and life of the patient. Adding to that the noble efforts in educating students and trainees to provide that public good, academic medicine is a virtuous endeavor. The new and growing phenomenon of private equity in healthcare prioritizes maximizing a return on investment, so the closure of Hahnemann University Hospital in Philadelphia highlights manifestations of the discordance of the missions of private equity and academic medicine and serves as “the canary in the coal mine,” warning teaching hospitals and communities that this disconnect necessitates regulatory policies to protect academic medicine’s service to the community while private equity investment continues to spread in healthcare.

The recent closure of Hahnemann University Hospital, a 500-bed teaching hospital in downtown Philadelphia, Pennsylvania, offers a case study of a new form of for-profit business involvement in academic medicine —private equity investment. Though the closure of this 171-year-old institution is the result of multiple factors affecting the hospital’s financial health over decades and may not have been avoidable, the hospital’s final years in the hands of a private equity firm led to a closure process that was chaotic, uncoordinated, and fundamentally not aligned with the needs of the patients and trainees that make up the core constituents of a teaching hospital. This hospital’s story involves a concerning trend that underscores the dissonance in mission of private equity and academic medicine. In an era of competition and market consolidation, other teaching hospitals may be forced to close under similar circumstances in the future, making it vital that the medical and academic communities be aware of these discordant missions to guide policy-making efforts and ensure that the needs of patients and trainees take priority in transition planning rather than the needs of investors.

Tracing the hospital’s history, much of its financial troubles began over 20 years ago. In 1993, the Allegheny Health, Education, and Research Foundation (AHERF), a nonprofit Pittsburgh-based hospital and physician practice organization, acquired Hahnemann Medical College. Forming the MCP-Hahnemann Medical School, AHERF merged the institution with another acquisition, Medical College of Pennsylvania (MCP),¹ formerly known as the Woman’s Medical College of Pennsylvania, one of the first American medical schools devoted to exclusively training female physicians.^1,2 This was part of AHERF’s aggressive growth strategy at the time and resulted in the acquisition of 14 hospitals and more than 300 Philadelphia-area primary care physician practices by 1998. This caused about $1.3 billion of debt and over $1 million in losses per day, which led AHERF to file for bankruptcy that year,² the country’s largest nonprofit healthcare bankruptcy at the time.¹ That same year, Tenet Healthcare Corporation, a for-profit healthcare company, bought AHERF’s assets in the Philadelphia region from bankruptcy for $345 million, acquiring eight hospitals, as well as all of AHREF’s physician practices.² Ultimately, Tenet sold or closed six of the acquired hospitals by 2007, leaving just Hahnemann and St. Christopher’s Hospital for Children,³ while Drexel University, a private, nonprofit university, came forward to salvage AHERF’s educational programs, creating the Drexel University College of Medicine.² Under the ownership of Tenet, Hahnemann’s financial health declined as its patient population included a growing proportion of those utilizing Medicare, Medicaid, and charity care, which resulted in a negative operating profit margin annually for the final 14 years under Tenet.^3,4 In this setting, American Academic Health System, LLC (AAHS) stepped in to purchase Hahnemann and St. Christopher’s from Tenet and, eventually, chose to close Hahnemann.⁴

That Hahnemann found itself in the hands of a private equity firm was not surprising. Such investment firms’ acquisitions of hospitals and physician practices have become increasingly more common, with the number of these types of deals increasing by 48% and reaching a value of $42.6 billion from 2010 to 2017.⁵ While for-profit hospitals have been shown to have higher mortality⁶ and lower patient satisfaction⁷ than nonprofit hospitals, the relatively new and growing trend of private equity investment in healthcare has not been rigorously evaluated. By nature, these firms use investor capital to acquire assets with the goal of increasing their value and selling them off at a profit after about 3-7 years.⁵ Thus, healthcare services provided by private equity–owned facilities are valued and supported based on their profitability. Low-profit services, such as primary care and psychiatry, are minimized while more profitable services, such as same-day surgery, are maximized.⁵ In addition, given that for-profit hospitals tend to invest less in charity care⁸ and population health⁹ as compared with nonprofit institutions, private equity–owned hospitals likely follow suit, in contrast to the humanistic values of academic medicine. Ultimately, Hahnemann’s decades-long financial troubles set the stage for a buyout by private equity investors. But this transaction was the death knell for this teaching hospital and eventually proved to be a disadvantage for the community it served.

Purchasing Hahnemann and St Christopher’s from Tenet in early 2018 for $170 million, AAHS—an affiliate of the private equity firm, Paladin Healthcare Capital, LLC, led by investment banker Joel Freedman—entered the Philadelphia healthcare market in partnership with Chicago-based healthcare real estate private equity firm, Harrison Street Real Estate Capital, LLC.⁴ Paladin had previously invested in smaller hospitals serving underserved communities,⁴ and as it began its venture with this large teaching hospital, Paladin’s president, Barry Wolfman, stated that the company’s goal was “to return [Hahnemann] to its rightful place in the landscape of healthcare.”³ However, given the real estate firm’s involvement in the deal and the permissive tier of zoning for Hahnemann’s real estate,1⁰ there were suspicions that the purchase of the hospital was a means to acquire and develop the valuable Center City real estate rather than to serve the community.³

Within months of the hospital purchase, AAHS‘s Philadelphia venture proved difficult. Four CEOs came and went as time passed, with some holding their position for only a couple of months.1¹ About 175 of Hahnemann’s nurses, support staff, and managers were laid off in April of 2019, but the hospital finances did not improve significantly.1² As it became evident that AAHS planned to close the hospital, efforts were made to prevent the closure. Drexel University filed an unsuccessful lawsuit, claiming that it would be a violation of the academic agreement between the university and hospital.1³ Once AAHS announced plans for hospital closure, the Pennsylvania Secretary of Health, Rachel Levine, MD, wrote to AAHS leadership ordering a “cease and desist” of any action toward hospital closure.¹² Despite this, AAHS began cutting vital hospital services, including trauma and cardiothoracic surgery services, within days of the closure announcement.¹⁴ While there is a state law that a hospital cannot be closed with less than 90 days’ notice, AAHS filed for bankruptcy and shut down Hahnemann’s service to the community in about half that time.¹³ The hospital real estate was separated from the operating businesses and was excluded from the bankruptcy filing,¹⁰ which further cemented suspicions that the involved private equity firms looked to profit off the land once the hospital closed.

The immediate and long-term effects of the closure of Hahnemann University Hospital on healthcare and medical education in Philadelphia are yet to be rigorously measured and evaluated. However, the hasty closure of a large inner-city teaching hospital that served as a healthcare safety net for a largely underserved minority population with 50,000 ED visits per year⁴ is a dangerous disruption to a community. The way that the hospital was closed not only defied regulatory attempts at protecting the community but also defied the values of the healthcare workers working in the hospital. Because AAHS ceased payments to hospital vendors, medical supplies were low during the final weeks at Hahnemann, which didn’t even have enough cups on the wards to provide drinking water for patients.¹⁵ Nurses reported feeling shame as they used scissors to cut wash cloths in half to have enough to wash their patients.¹⁵ The teaching hospital’s humanistic and social capital was being liquidated quickly. Even after Hahnemann’s 570 graduate medical trainees endured the stressful and chaotic process of being displaced and fortunately taken in by other programs,¹⁶ AAHS attempted to auction off Hahnemann’s graduate medical education (GME) slots and their associated government funding to the highest bidder. While a US bankruptcy judge initially approved the sale of those GME slots to a consortium of academic institutions in the Philadelphia area,¹⁷ the Center for Medicare & Medicaid Services (CMS) has appealed that decision, which resulted in a current stay on the transaction.¹⁷ AAHS treating GME trainee positions as assets to be bought and sold is a dangerous precedent to set, especially since it attempts to bypass CMS’s existing regulated process for redistributing the slots.

While time will reveal the effects of the hospital closure, the most concerning element of this story is that the methods of a private equity firm in closing a large inner-city teaching hospital flouted attempts by regulatory agencies acting to preserve the hospital’s mission to the community. The governor of Pennsylvania, Tom Wolf (D), and mayor of Philadelphia, Jim Kenney (D), issued a joint statement chastising the actions of AAHS: “The situation at Hahnemann University Hospital, caused by CEO Joel Freedman and his team of venture capitalists, is an absolute disgrace and shows a greed-driven lack of care for the community.”1⁸ This chaotic situation inspired Philadelphia Councilperson Helen Gym (D) to propose city legislation requiring 180 days’ notice of a hospital closure, bestowing a strong local means of protecting the city’s people from similar healthcare fiascos in the future.¹⁵

At its core, healthcare is a human-to-human interaction with the purpose of improving and maintaining the health and life of the patient. Adding to that the noble efforts in educating students and trainees to provide that public good, academic medicine is a virtuous endeavor. The new and growing phenomenon of private equity in healthcare prioritizes maximizing a return on investment, so the closure of Hahnemann University Hospital in Philadelphia highlights manifestations of the discordance of the missions of private equity and academic medicine and serves as “the canary in the coal mine,” warning teaching hospitals and communities that this disconnect necessitates regulatory policies to protect academic medicine’s service to the community while private equity investment continues to spread in healthcare.

The recent closure of Hahnemann University Hospital, a 500-bed teaching hospital in downtown Philadelphia, Pennsylvania, offers a case study of a new form of for-profit business involvement in academic medicine —private equity investment. Though the closure of this 171-year-old institution is the result of multiple factors affecting the hospital’s financial health over decades and may not have been avoidable, the hospital’s final years in the hands of a private equity firm led to a closure process that was chaotic, uncoordinated, and fundamentally not aligned with the needs of the patients and trainees that make up the core constituents of a teaching hospital. This hospital’s story involves a concerning trend that underscores the dissonance in mission of private equity and academic medicine. In an era of competition and market consolidation, other teaching hospitals may be forced to close under similar circumstances in the future, making it vital that the medical and academic communities be aware of these discordant missions to guide policy-making efforts and ensure that the needs of patients and trainees take priority in transition planning rather than the needs of investors.

Tracing the hospital’s history, much of its financial troubles began over 20 years ago. In 1993, the Allegheny Health, Education, and Research Foundation (AHERF), a nonprofit Pittsburgh-based hospital and physician practice organization, acquired Hahnemann Medical College. Forming the MCP-Hahnemann Medical School, AHERF merged the institution with another acquisition, Medical College of Pennsylvania (MCP),¹ formerly known as the Woman’s Medical College of Pennsylvania, one of the first American medical schools devoted to exclusively training female physicians.^1,2 This was part of AHERF’s aggressive growth strategy at the time and resulted in the acquisition of 14 hospitals and more than 300 Philadelphia-area primary care physician practices by 1998. This caused about $1.3 billion of debt and over $1 million in losses per day, which led AHERF to file for bankruptcy that year,² the country’s largest nonprofit healthcare bankruptcy at the time.¹ That same year, Tenet Healthcare Corporation, a for-profit healthcare company, bought AHERF’s assets in the Philadelphia region from bankruptcy for $345 million, acquiring eight hospitals, as well as all of AHREF’s physician practices.² Ultimately, Tenet sold or closed six of the acquired hospitals by 2007, leaving just Hahnemann and St. Christopher’s Hospital for Children,³ while Drexel University, a private, nonprofit university, came forward to salvage AHERF’s educational programs, creating the Drexel University College of Medicine.² Under the ownership of Tenet, Hahnemann’s financial health declined as its patient population included a growing proportion of those utilizing Medicare, Medicaid, and charity care, which resulted in a negative operating profit margin annually for the final 14 years under Tenet.^3,4 In this setting, American Academic Health System, LLC (AAHS) stepped in to purchase Hahnemann and St. Christopher’s from Tenet and, eventually, chose to close Hahnemann.⁴

That Hahnemann found itself in the hands of a private equity firm was not surprising. Such investment firms’ acquisitions of hospitals and physician practices have become increasingly more common, with the number of these types of deals increasing by 48% and reaching a value of $42.6 billion from 2010 to 2017.⁵ While for-profit hospitals have been shown to have higher mortality⁶ and lower patient satisfaction⁷ than nonprofit hospitals, the relatively new and growing trend of private equity investment in healthcare has not been rigorously evaluated. By nature, these firms use investor capital to acquire assets with the goal of increasing their value and selling them off at a profit after about 3-7 years.⁵ Thus, healthcare services provided by private equity–owned facilities are valued and supported based on their profitability. Low-profit services, such as primary care and psychiatry, are minimized while more profitable services, such as same-day surgery, are maximized.⁵ In addition, given that for-profit hospitals tend to invest less in charity care⁸ and population health⁹ as compared with nonprofit institutions, private equity–owned hospitals likely follow suit, in contrast to the humanistic values of academic medicine. Ultimately, Hahnemann’s decades-long financial troubles set the stage for a buyout by private equity investors. But this transaction was the death knell for this teaching hospital and eventually proved to be a disadvantage for the community it served.

Purchasing Hahnemann and St Christopher’s from Tenet in early 2018 for $170 million, AAHS—an affiliate of the private equity firm, Paladin Healthcare Capital, LLC, led by investment banker Joel Freedman—entered the Philadelphia healthcare market in partnership with Chicago-based healthcare real estate private equity firm, Harrison Street Real Estate Capital, LLC.⁴ Paladin had previously invested in smaller hospitals serving underserved communities,⁴ and as it began its venture with this large teaching hospital, Paladin’s president, Barry Wolfman, stated that the company’s goal was “to return [Hahnemann] to its rightful place in the landscape of healthcare.”³ However, given the real estate firm’s involvement in the deal and the permissive tier of zoning for Hahnemann’s real estate,1⁰ there were suspicions that the purchase of the hospital was a means to acquire and develop the valuable Center City real estate rather than to serve the community.³

Within months of the hospital purchase, AAHS‘s Philadelphia venture proved difficult. Four CEOs came and went as time passed, with some holding their position for only a couple of months.1¹ About 175 of Hahnemann’s nurses, support staff, and managers were laid off in April of 2019, but the hospital finances did not improve significantly.1² As it became evident that AAHS planned to close the hospital, efforts were made to prevent the closure. Drexel University filed an unsuccessful lawsuit, claiming that it would be a violation of the academic agreement between the university and hospital.1³ Once AAHS announced plans for hospital closure, the Pennsylvania Secretary of Health, Rachel Levine, MD, wrote to AAHS leadership ordering a “cease and desist” of any action toward hospital closure.¹² Despite this, AAHS began cutting vital hospital services, including trauma and cardiothoracic surgery services, within days of the closure announcement.¹⁴ While there is a state law that a hospital cannot be closed with less than 90 days’ notice, AAHS filed for bankruptcy and shut down Hahnemann’s service to the community in about half that time.¹³ The hospital real estate was separated from the operating businesses and was excluded from the bankruptcy filing,¹⁰ which further cemented suspicions that the involved private equity firms looked to profit off the land once the hospital closed.

The immediate and long-term effects of the closure of Hahnemann University Hospital on healthcare and medical education in Philadelphia are yet to be rigorously measured and evaluated. However, the hasty closure of a large inner-city teaching hospital that served as a healthcare safety net for a largely underserved minority population with 50,000 ED visits per year⁴ is a dangerous disruption to a community. The way that the hospital was closed not only defied regulatory attempts at protecting the community but also defied the values of the healthcare workers working in the hospital. Because AAHS ceased payments to hospital vendors, medical supplies were low during the final weeks at Hahnemann, which didn’t even have enough cups on the wards to provide drinking water for patients.¹⁵ Nurses reported feeling shame as they used scissors to cut wash cloths in half to have enough to wash their patients.¹⁵ The teaching hospital’s humanistic and social capital was being liquidated quickly. Even after Hahnemann’s 570 graduate medical trainees endured the stressful and chaotic process of being displaced and fortunately taken in by other programs,¹⁶ AAHS attempted to auction off Hahnemann’s graduate medical education (GME) slots and their associated government funding to the highest bidder. While a US bankruptcy judge initially approved the sale of those GME slots to a consortium of academic institutions in the Philadelphia area,¹⁷ the Center for Medicare & Medicaid Services (CMS) has appealed that decision, which resulted in a current stay on the transaction.¹⁷ AAHS treating GME trainee positions as assets to be bought and sold is a dangerous precedent to set, especially since it attempts to bypass CMS’s existing regulated process for redistributing the slots.

While time will reveal the effects of the hospital closure, the most concerning element of this story is that the methods of a private equity firm in closing a large inner-city teaching hospital flouted attempts by regulatory agencies acting to preserve the hospital’s mission to the community. The governor of Pennsylvania, Tom Wolf (D), and mayor of Philadelphia, Jim Kenney (D), issued a joint statement chastising the actions of AAHS: “The situation at Hahnemann University Hospital, caused by CEO Joel Freedman and his team of venture capitalists, is an absolute disgrace and shows a greed-driven lack of care for the community.”1⁸ This chaotic situation inspired Philadelphia Councilperson Helen Gym (D) to propose city legislation requiring 180 days’ notice of a hospital closure, bestowing a strong local means of protecting the city’s people from similar healthcare fiascos in the future.¹⁵

At its core, healthcare is a human-to-human interaction with the purpose of improving and maintaining the health and life of the patient. Adding to that the noble efforts in educating students and trainees to provide that public good, academic medicine is a virtuous endeavor. The new and growing phenomenon of private equity in healthcare prioritizes maximizing a return on investment, so the closure of Hahnemann University Hospital in Philadelphia highlights manifestations of the discordance of the missions of private equity and academic medicine and serves as “the canary in the coal mine,” warning teaching hospitals and communities that this disconnect necessitates regulatory policies to protect academic medicine’s service to the community while private equity investment continues to spread in healthcare.

Pediatric hospital medicine (PHM) is in the midst of an exciting period of growth. In 2016, the American Board of Medical Specialties approved the petition for PHM to become the newest pediatric subspecialty, taking PHM on a divergent path from the Focused Practice in Hospital Medicine designation established for adult hospitalists. Establishment as a subspecialty has allowed PHM to define the unique skills and qualifications that hospitalists bring to patients and the healthcare system. These skills and qualifications are delineated in the PHM core competencies and national fellowship curriculum.^1,2 In order to realize the vision of PHM to improve care for hospitalized children described by Roberts et al.,³ concerted efforts are needed to train and retain a workforce that is equipped with the skills to catalyze improvements in inpatient pediatric care. We discuss challenges and opportunities facing PHM in workforce development, sustainability of clinical work models, and interhospital collaboration.

The development of PHM as a subspecialty was driven by a number of factors.⁴ The acuity of hospitalized children has increased significantly, with a population comprised of more children with complex chronic conditions and/or technology dependence, serious complications of acute conditions, and acute mental health problems. At the same time, the medical and behavioral conditions seen by outpatient general pediatricians have become more complex and time intensive, with these practitioners less likely to work in inpatient settings. Hospitalist care has positive impacts on healthcare efficiency and value, and both parents and primary care pediatricians report high levels of satisfaction with the healthcare delivered by PHM services.⁴

A national count of the number of pediatric hospitalists is currently lacking. Conservative estimates suggest that at least 3,000 pediatric hospitalists currently practice in the United States.⁵ These hospitalists have highly varied scopes of practice and work across diverse settings—more diverse, perhaps, than any other pediatric subspecialty. Although difficult to quantify, we estimate that approximately one-third of pediatric hospitalists in the US work in community hospitals and the remainder practice at children’s hospitals.⁶ Many of the needs of hospitalized children differ across these settings, and the roles and challenges faced by hospitalists in these settings correspondingly differ. Community hospitalists frequently take active roles in newborn care and emergency department consultation, often without the support of other pediatric subspecialties.⁷ In contrast, hospitalists working at children’s hospitals more frequently care for highly complex patients, often collaborate across multiple specialties and assume nonclinical roles in quality improvement (QI), research, and medical education.

Residents graduating in July 2019 were the last cohort of residents eligible to pursue PHM subspecialty certification via the practice pathway. Accordingly, future residency graduates interested in PHM subspecialty certification will need to complete a PHM fellowship at an accredited program in the US or Canada. Since 2008, PHM fellowship directors have met yearly to collaborate and share best practices,⁸ developing the two-year fellowship curriculum that forms the basis for the American Board of Pediatrics training pathway.² The curriculum allows significant flexibility to meet diverse needs, including tailored content for fellows planning to practice in community settings, fellows planning research careers, medicine-pediatrics hospitalist careers, and those desiring increased training in QI, medical education, or leadership/administration.² In the spring of 2019, Pediatric Research in Inpatient Settings (PRIS) leadership, directors of existing PHM fellowship programs, and national academic society representatives met to develop a fellows’ research curriculum, training resources, and guidelines around scholarship expectations.⁹ This collaboration aims to accelerate the growth of high-quality clinical training and scholarship to benefit hospitalized children across many different settings.

Such collaboration is essential to address an emerging workforce challenge in PHM. Although the number of PHM fellowship positions is expected to grow in the coming years, there is currently a shortage relative to the anticipated demand. With approximately 2,800 US pediatric residents graduating annually and data indicating that 7% of graduating residents enter and remain in PHM for at least five years,^10,11 almost 200 fellowship spots may be needed each year. As of November 2019, 77 fellowship positions were available for residents graduating in 2020,¹² which is less than half of the potential demand. To address this mismatch, the PHM Fellowship Directors’ Council has led an annual training for new and potential fellowship directors, and 18 new programs are under development.¹³ However, this growth may be inadequate to meet the needs of the field. The extent to which limited PHM fellowship positions will adversely affect the pipeline of pediatricians pursuing PHM is unknown.

Efforts to support institutions in creating and expanding fellowship programs will be needed to address the potential shortage of fellowship positions. Continued guidance from the PHM Fellowship Directors’ Council in the many aspects of fellowship program development (eg, curriculum design, assessment) will be crucial in this endeavor. Furthermore, given that fellowships must support fellows to conduct scholarly work and demonstrate evidence of robust faculty scholarly activities to attain accreditation, an essential area of focus is faculty development. Considering barriers such as lack of time, mentorship, and resources, some divisions interested in starting a fellowship may find it challenging to achieve these standards.¹⁴ However, hospitalists are often engaged in areas such as QI and medical education, and there is potential to turn ongoing work into meaningful scholarship with appropriate guidance. Many of our supporting organizations (eg, Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine) provide training programs for faculty in areas such as educational scholarship, research, and QI; however, more may be needed. Leaders of PHM programs will need to be mindful and creative in accessing local, regional, and national resources to invest in faculty development.

As a group, pediatric hospitalists report high levels of satisfaction with their jobs.¹¹ Despite this finding, there are a number of threats to the sustainability of current work models, some of which are unique to pediatrics given the overall lower patient volumes and greater seasonal variation compared with adult hospital medicine. Both university and community-based hospitalist programs report high weekend, overnight, and in-house clinical effort.^7,15 Recent studies reported that a significant proportion of PHM program leaders (50% of division directors at university-affiliated programs and 37% of community program leaders) perceive their program to be unsustainable.^7,15 Among university-affiliated programs, a higher burden of weekend work as well as university employment were associated with perceived unsustainability, while no specific program or employer characteristic was associated with this perception in community programs.

These findings indicate that efforts are needed to address PHM program sustainability and that different work models and interventions may be needed for university-based and community PHM programs. Wide variability exists in the ways that programs address overall clinical burden, with strategies including census caps, seasonal expansion of coverage, and formal back-up systems.^7,15 Additional potential solutions may include differential weighting or financial incentives for nights and weekends, support for nonclinical work, loan repayment programs, and competitive salaries.¹¹ In addition, structuring clinical and nonclinical roles to facilitate career development and advancement may enhance career longevity.¹⁵ Lessons learned from pediatric emergency medicine (PEM), which developed as a field a few decades ahead of PHM, may predict future challenges. A 2015 survey of PEM faculty found that despite a 15% decrease in weekly work hours over a 15-year period, a substantial number of PEM faculty report concerns about burnout, with 40% reporting a plan to decrease their clinical workload and 13% planning to leave the field within five years.¹⁶ Like PEM, the field of PHM may benefit from the development of best practice guidelines to improve well-being and career longevity.¹⁷

The culture of collaboration within PHM places the field in a solid position to address both workforce challenges and barriers to high-quality care for hospitalized children. There are several hospital-based learning networks actively working to strengthen our knowledge base and improve healthcare quality. The PRIS network (www.prisnetwork.org) aims to improve healthcare for children through multihospital studies, boasting 114 sites in the US and Canada. Numerous collaborative projects have linked hospitalists across programs to tackle problems ranging from handoff communication¹⁸ to eliminating monitor overuse.¹⁹ The Value in Inpatient Pediatrics network has similarly leveraged collaborations across multiple children’s and community hospitals to improve transitions of care²⁰ and care for common conditions such as bronchiolitis, febrile infants, and asthma.²¹ These networks serve as models of effective collaboration between children’s hospitals and community hospitals, more of which is needed to increase research and QI initiatives in community hospitals, where the majority of US children receive their hospital-based care.^6,22

With the rapid growth of scholarly networks in research, QI, and education, PHM has a solid infrastructure on which to base continued development as a subspeciality. Building on this infrastructure will be essential in order to address current challenges in workforce development, fellowship training, and program sustainability. Ultimately, achieving a strong, stable, and skilled workforce will enable PHM to fulfill its promise of improving the care of children across the diversity of settings where they receive their hospital-based care.

Disclosures

Dr. Leyenaar provides consultative services to the American Board of Pediatrics Foundation, which is not associated with this manuscript. Drs. Wang and Shaughnessy have no disclosures

Pediatric hospital medicine (PHM) is in the midst of an exciting period of growth. In 2016, the American Board of Medical Specialties approved the petition for PHM to become the newest pediatric subspecialty, taking PHM on a divergent path from the Focused Practice in Hospital Medicine designation established for adult hospitalists. Establishment as a subspecialty has allowed PHM to define the unique skills and qualifications that hospitalists bring to patients and the healthcare system. These skills and qualifications are delineated in the PHM core competencies and national fellowship curriculum.^1,2 In order to realize the vision of PHM to improve care for hospitalized children described by Roberts et al.,³ concerted efforts are needed to train and retain a workforce that is equipped with the skills to catalyze improvements in inpatient pediatric care. We discuss challenges and opportunities facing PHM in workforce development, sustainability of clinical work models, and interhospital collaboration.

The development of PHM as a subspecialty was driven by a number of factors.⁴ The acuity of hospitalized children has increased significantly, with a population comprised of more children with complex chronic conditions and/or technology dependence, serious complications of acute conditions, and acute mental health problems. At the same time, the medical and behavioral conditions seen by outpatient general pediatricians have become more complex and time intensive, with these practitioners less likely to work in inpatient settings. Hospitalist care has positive impacts on healthcare efficiency and value, and both parents and primary care pediatricians report high levels of satisfaction with the healthcare delivered by PHM services.⁴

A national count of the number of pediatric hospitalists is currently lacking. Conservative estimates suggest that at least 3,000 pediatric hospitalists currently practice in the United States.⁵ These hospitalists have highly varied scopes of practice and work across diverse settings—more diverse, perhaps, than any other pediatric subspecialty. Although difficult to quantify, we estimate that approximately one-third of pediatric hospitalists in the US work in community hospitals and the remainder practice at children’s hospitals.⁶ Many of the needs of hospitalized children differ across these settings, and the roles and challenges faced by hospitalists in these settings correspondingly differ. Community hospitalists frequently take active roles in newborn care and emergency department consultation, often without the support of other pediatric subspecialties.⁷ In contrast, hospitalists working at children’s hospitals more frequently care for highly complex patients, often collaborate across multiple specialties and assume nonclinical roles in quality improvement (QI), research, and medical education.

Residents graduating in July 2019 were the last cohort of residents eligible to pursue PHM subspecialty certification via the practice pathway. Accordingly, future residency graduates interested in PHM subspecialty certification will need to complete a PHM fellowship at an accredited program in the US or Canada. Since 2008, PHM fellowship directors have met yearly to collaborate and share best practices,⁸ developing the two-year fellowship curriculum that forms the basis for the American Board of Pediatrics training pathway.² The curriculum allows significant flexibility to meet diverse needs, including tailored content for fellows planning to practice in community settings, fellows planning research careers, medicine-pediatrics hospitalist careers, and those desiring increased training in QI, medical education, or leadership/administration.² In the spring of 2019, Pediatric Research in Inpatient Settings (PRIS) leadership, directors of existing PHM fellowship programs, and national academic society representatives met to develop a fellows’ research curriculum, training resources, and guidelines around scholarship expectations.⁹ This collaboration aims to accelerate the growth of high-quality clinical training and scholarship to benefit hospitalized children across many different settings.

Such collaboration is essential to address an emerging workforce challenge in PHM. Although the number of PHM fellowship positions is expected to grow in the coming years, there is currently a shortage relative to the anticipated demand. With approximately 2,800 US pediatric residents graduating annually and data indicating that 7% of graduating residents enter and remain in PHM for at least five years,^10,11 almost 200 fellowship spots may be needed each year. As of November 2019, 77 fellowship positions were available for residents graduating in 2020,¹² which is less than half of the potential demand. To address this mismatch, the PHM Fellowship Directors’ Council has led an annual training for new and potential fellowship directors, and 18 new programs are under development.¹³ However, this growth may be inadequate to meet the needs of the field. The extent to which limited PHM fellowship positions will adversely affect the pipeline of pediatricians pursuing PHM is unknown.

Efforts to support institutions in creating and expanding fellowship programs will be needed to address the potential shortage of fellowship positions. Continued guidance from the PHM Fellowship Directors’ Council in the many aspects of fellowship program development (eg, curriculum design, assessment) will be crucial in this endeavor. Furthermore, given that fellowships must support fellows to conduct scholarly work and demonstrate evidence of robust faculty scholarly activities to attain accreditation, an essential area of focus is faculty development. Considering barriers such as lack of time, mentorship, and resources, some divisions interested in starting a fellowship may find it challenging to achieve these standards.¹⁴ However, hospitalists are often engaged in areas such as QI and medical education, and there is potential to turn ongoing work into meaningful scholarship with appropriate guidance. Many of our supporting organizations (eg, Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine) provide training programs for faculty in areas such as educational scholarship, research, and QI; however, more may be needed. Leaders of PHM programs will need to be mindful and creative in accessing local, regional, and national resources to invest in faculty development.

As a group, pediatric hospitalists report high levels of satisfaction with their jobs.¹¹ Despite this finding, there are a number of threats to the sustainability of current work models, some of which are unique to pediatrics given the overall lower patient volumes and greater seasonal variation compared with adult hospital medicine. Both university and community-based hospitalist programs report high weekend, overnight, and in-house clinical effort.^7,15 Recent studies reported that a significant proportion of PHM program leaders (50% of division directors at university-affiliated programs and 37% of community program leaders) perceive their program to be unsustainable.^7,15 Among university-affiliated programs, a higher burden of weekend work as well as university employment were associated with perceived unsustainability, while no specific program or employer characteristic was associated with this perception in community programs.

These findings indicate that efforts are needed to address PHM program sustainability and that different work models and interventions may be needed for university-based and community PHM programs. Wide variability exists in the ways that programs address overall clinical burden, with strategies including census caps, seasonal expansion of coverage, and formal back-up systems.^7,15 Additional potential solutions may include differential weighting or financial incentives for nights and weekends, support for nonclinical work, loan repayment programs, and competitive salaries.¹¹ In addition, structuring clinical and nonclinical roles to facilitate career development and advancement may enhance career longevity.¹⁵ Lessons learned from pediatric emergency medicine (PEM), which developed as a field a few decades ahead of PHM, may predict future challenges. A 2015 survey of PEM faculty found that despite a 15% decrease in weekly work hours over a 15-year period, a substantial number of PEM faculty report concerns about burnout, with 40% reporting a plan to decrease their clinical workload and 13% planning to leave the field within five years.¹⁶ Like PEM, the field of PHM may benefit from the development of best practice guidelines to improve well-being and career longevity.¹⁷

The culture of collaboration within PHM places the field in a solid position to address both workforce challenges and barriers to high-quality care for hospitalized children. There are several hospital-based learning networks actively working to strengthen our knowledge base and improve healthcare quality. The PRIS network (www.prisnetwork.org) aims to improve healthcare for children through multihospital studies, boasting 114 sites in the US and Canada. Numerous collaborative projects have linked hospitalists across programs to tackle problems ranging from handoff communication¹⁸ to eliminating monitor overuse.¹⁹ The Value in Inpatient Pediatrics network has similarly leveraged collaborations across multiple children’s and community hospitals to improve transitions of care²⁰ and care for common conditions such as bronchiolitis, febrile infants, and asthma.²¹ These networks serve as models of effective collaboration between children’s hospitals and community hospitals, more of which is needed to increase research and QI initiatives in community hospitals, where the majority of US children receive their hospital-based care.^6,22

With the rapid growth of scholarly networks in research, QI, and education, PHM has a solid infrastructure on which to base continued development as a subspeciality. Building on this infrastructure will be essential in order to address current challenges in workforce development, fellowship training, and program sustainability. Ultimately, achieving a strong, stable, and skilled workforce will enable PHM to fulfill its promise of improving the care of children across the diversity of settings where they receive their hospital-based care.

Disclosures

Dr. Leyenaar provides consultative services to the American Board of Pediatrics Foundation, which is not associated with this manuscript. Drs. Wang and Shaughnessy have no disclosures

Pediatric hospital medicine (PHM) is in the midst of an exciting period of growth. In 2016, the American Board of Medical Specialties approved the petition for PHM to become the newest pediatric subspecialty, taking PHM on a divergent path from the Focused Practice in Hospital Medicine designation established for adult hospitalists. Establishment as a subspecialty has allowed PHM to define the unique skills and qualifications that hospitalists bring to patients and the healthcare system. These skills and qualifications are delineated in the PHM core competencies and national fellowship curriculum.^1,2 In order to realize the vision of PHM to improve care for hospitalized children described by Roberts et al.,³ concerted efforts are needed to train and retain a workforce that is equipped with the skills to catalyze improvements in inpatient pediatric care. We discuss challenges and opportunities facing PHM in workforce development, sustainability of clinical work models, and interhospital collaboration.

The development of PHM as a subspecialty was driven by a number of factors.⁴ The acuity of hospitalized children has increased significantly, with a population comprised of more children with complex chronic conditions and/or technology dependence, serious complications of acute conditions, and acute mental health problems. At the same time, the medical and behavioral conditions seen by outpatient general pediatricians have become more complex and time intensive, with these practitioners less likely to work in inpatient settings. Hospitalist care has positive impacts on healthcare efficiency and value, and both parents and primary care pediatricians report high levels of satisfaction with the healthcare delivered by PHM services.⁴

A national count of the number of pediatric hospitalists is currently lacking. Conservative estimates suggest that at least 3,000 pediatric hospitalists currently practice in the United States.⁵ These hospitalists have highly varied scopes of practice and work across diverse settings—more diverse, perhaps, than any other pediatric subspecialty. Although difficult to quantify, we estimate that approximately one-third of pediatric hospitalists in the US work in community hospitals and the remainder practice at children’s hospitals.⁶ Many of the needs of hospitalized children differ across these settings, and the roles and challenges faced by hospitalists in these settings correspondingly differ. Community hospitalists frequently take active roles in newborn care and emergency department consultation, often without the support of other pediatric subspecialties.⁷ In contrast, hospitalists working at children’s hospitals more frequently care for highly complex patients, often collaborate across multiple specialties and assume nonclinical roles in quality improvement (QI), research, and medical education.

Residents graduating in July 2019 were the last cohort of residents eligible to pursue PHM subspecialty certification via the practice pathway. Accordingly, future residency graduates interested in PHM subspecialty certification will need to complete a PHM fellowship at an accredited program in the US or Canada. Since 2008, PHM fellowship directors have met yearly to collaborate and share best practices,⁸ developing the two-year fellowship curriculum that forms the basis for the American Board of Pediatrics training pathway.² The curriculum allows significant flexibility to meet diverse needs, including tailored content for fellows planning to practice in community settings, fellows planning research careers, medicine-pediatrics hospitalist careers, and those desiring increased training in QI, medical education, or leadership/administration.² In the spring of 2019, Pediatric Research in Inpatient Settings (PRIS) leadership, directors of existing PHM fellowship programs, and national academic society representatives met to develop a fellows’ research curriculum, training resources, and guidelines around scholarship expectations.⁹ This collaboration aims to accelerate the growth of high-quality clinical training and scholarship to benefit hospitalized children across many different settings.

Such collaboration is essential to address an emerging workforce challenge in PHM. Although the number of PHM fellowship positions is expected to grow in the coming years, there is currently a shortage relative to the anticipated demand. With approximately 2,800 US pediatric residents graduating annually and data indicating that 7% of graduating residents enter and remain in PHM for at least five years,^10,11 almost 200 fellowship spots may be needed each year. As of November 2019, 77 fellowship positions were available for residents graduating in 2020,¹² which is less than half of the potential demand. To address this mismatch, the PHM Fellowship Directors’ Council has led an annual training for new and potential fellowship directors, and 18 new programs are under development.¹³ However, this growth may be inadequate to meet the needs of the field. The extent to which limited PHM fellowship positions will adversely affect the pipeline of pediatricians pursuing PHM is unknown.

Efforts to support institutions in creating and expanding fellowship programs will be needed to address the potential shortage of fellowship positions. Continued guidance from the PHM Fellowship Directors’ Council in the many aspects of fellowship program development (eg, curriculum design, assessment) will be crucial in this endeavor. Furthermore, given that fellowships must support fellows to conduct scholarly work and demonstrate evidence of robust faculty scholarly activities to attain accreditation, an essential area of focus is faculty development. Considering barriers such as lack of time, mentorship, and resources, some divisions interested in starting a fellowship may find it challenging to achieve these standards.¹⁴ However, hospitalists are often engaged in areas such as QI and medical education, and there is potential to turn ongoing work into meaningful scholarship with appropriate guidance. Many of our supporting organizations (eg, Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine) provide training programs for faculty in areas such as educational scholarship, research, and QI; however, more may be needed. Leaders of PHM programs will need to be mindful and creative in accessing local, regional, and national resources to invest in faculty development.

As a group, pediatric hospitalists report high levels of satisfaction with their jobs.¹¹ Despite this finding, there are a number of threats to the sustainability of current work models, some of which are unique to pediatrics given the overall lower patient volumes and greater seasonal variation compared with adult hospital medicine. Both university and community-based hospitalist programs report high weekend, overnight, and in-house clinical effort.^7,15 Recent studies reported that a significant proportion of PHM program leaders (50% of division directors at university-affiliated programs and 37% of community program leaders) perceive their program to be unsustainable.^7,15 Among university-affiliated programs, a higher burden of weekend work as well as university employment were associated with perceived unsustainability, while no specific program or employer characteristic was associated with this perception in community programs.

These findings indicate that efforts are needed to address PHM program sustainability and that different work models and interventions may be needed for university-based and community PHM programs. Wide variability exists in the ways that programs address overall clinical burden, with strategies including census caps, seasonal expansion of coverage, and formal back-up systems.^7,15 Additional potential solutions may include differential weighting or financial incentives for nights and weekends, support for nonclinical work, loan repayment programs, and competitive salaries.¹¹ In addition, structuring clinical and nonclinical roles to facilitate career development and advancement may enhance career longevity.¹⁵ Lessons learned from pediatric emergency medicine (PEM), which developed as a field a few decades ahead of PHM, may predict future challenges. A 2015 survey of PEM faculty found that despite a 15% decrease in weekly work hours over a 15-year period, a substantial number of PEM faculty report concerns about burnout, with 40% reporting a plan to decrease their clinical workload and 13% planning to leave the field within five years.¹⁶ Like PEM, the field of PHM may benefit from the development of best practice guidelines to improve well-being and career longevity.¹⁷

The culture of collaboration within PHM places the field in a solid position to address both workforce challenges and barriers to high-quality care for hospitalized children. There are several hospital-based learning networks actively working to strengthen our knowledge base and improve healthcare quality. The PRIS network (www.prisnetwork.org) aims to improve healthcare for children through multihospital studies, boasting 114 sites in the US and Canada. Numerous collaborative projects have linked hospitalists across programs to tackle problems ranging from handoff communication¹⁸ to eliminating monitor overuse.¹⁹ The Value in Inpatient Pediatrics network has similarly leveraged collaborations across multiple children’s and community hospitals to improve transitions of care²⁰ and care for common conditions such as bronchiolitis, febrile infants, and asthma.²¹ These networks serve as models of effective collaboration between children’s hospitals and community hospitals, more of which is needed to increase research and QI initiatives in community hospitals, where the majority of US children receive their hospital-based care.^6,22

With the rapid growth of scholarly networks in research, QI, and education, PHM has a solid infrastructure on which to base continued development as a subspeciality. Building on this infrastructure will be essential in order to address current challenges in workforce development, fellowship training, and program sustainability. Ultimately, achieving a strong, stable, and skilled workforce will enable PHM to fulfill its promise of improving the care of children across the diversity of settings where they receive their hospital-based care.

Disclosures

Dr. Leyenaar provides consultative services to the American Board of Pediatrics Foundation, which is not associated with this manuscript. Drs. Wang and Shaughnessy have no disclosures

Traditional mentorship models may not be adequate for academic hospitalists. The traditional dyadic mentorship model, in which a senior principal investigator and research mentee collaborate for career advancement, is well suited for basic science or clinical research. In contrast, areas of academic hospital medicine such as quality improvement, medical education, hospital operations, point-of-care ultrasound, and clinical expertise may be less suited to this traditional mentoring model. In addition, experienced mentors are limited and those available are often overcommitted or have inadequate time due to responsibilities with other leadership roles. Senior mentors may also be limited because of our specialty’s focus on clinical practice rather than longitudinal research or projects.⁹ There are other limitations of traditional mentorship that are applicable to all fields of academic medicine, including disparate goals, expectations, levels of commitment, and the inherent power differential between the mentor and mentee.¹⁰

In this perspective, we discuss our experience with implementing an alternative and complementary mentorship strategy called facilitated peer mentorship with junior faculty hospitalists in the Division of General Internal Medicine at New York–Presbyterian/Weill Cornell Medical Center.

In facilitated peer mentoring programs, faculty typically work collaboratively in groups of three to five with other faculty who are of similar rank, and a faculty member of a higher academic rank works with the group in meeting their scholarly goals.¹¹ The role of the facilitator is to ensure a safe and respectful learning environment, foster peer collaboration, and redirect the group to draw upon their own experiences. Each junior faculty member serves as both a mentor and mentee for each other with bidirectional feedback, guidance, and support in a group setting. This model emphasizes collaboration, peer networking, empowerment, and the development of personal awareness.¹⁰ A number of academic medical centers have used peer mentoring as a response to the challenges encountered in the traditional dyad model.¹² To our knowledge, the only published example of a peer mentoring model in academic hospital medicine is in the form of a research-in-progress conference.¹³ While this example addresses peer-mentored research, there is a gap in other areas of academic hospital medicine with mentoring needs—most of all in personal development and career satisfaction.

We piloted a 12-month facilitated peer mentoring program for new hospitalists. The goal of the program was for junior faculty hospitalists to develop a better understanding of their own identity and core values that would enable them to more confidently navigate career choices, enhance their work vitality and career satisfaction, and develop their potential for leadership roles in academic hospital medicine. Each year, a cohort of four to five incoming hospitalists from different backgrounds, interests, and experience were grouped with a more experienced colleague at an associate professor rank who expressed interest and was selected by our section chief to lead the program. The program was required for new hospitalists and consisted of six 90-minute sessions every two months. The attendance rate was 100% and was ensured by scheduling all sessions at the beginning of the academic year with dates agreed upon by all participants. An e-mail reminder was sent one week prior to each session. Each session had assigned readings and an agenda for discussions (see Table for details).

Our evaluation of the program after two years with two separate cohorts included qualitative feedback through an anonymous survey for participants; in addition, qualitative feedback was collected in a one-hour, in-person discussion and reflection with each cohort. We learned several lessons from the feedback we received from program participants. First, our impression was that the career experience of the junior faculty member had a significant impact on the perceived value of group meetings. For those who entered the hospitalist workforce immediately upon completing their terminal training in internal medicine, the exercise of considering different career versions of themselves had added value in promoting thinking outside-the-box for career opportunities within hospital medicine. Academic hospitalists and general internists more broadly, tend to have broad interests that fuel their passions but may also make it more difficult to define long-term goals. One junior faculty member paired her life interests in global medical education with building an international collaboration with other academic hospitalist programs; another faculty member gained confidence and expanded her network of collaborators by designing a research pilot study on hospitalist-initiated end-of-life discussions. In both cases, the junior faculty identified the facilitated peer mentoring program as a strong influence in finding these opportunities. Peer mentoring at the time of entry into the field of hospital medicine, when many have undefined career goals, can be helpful for navigating this issue at the start of a career. On the other hand, those who had already worked as a hospitalist for one or two years and joined the program found less value in career planning exercises.

Second, junior faculty differed in their desire for scope and depth of the curriculum. Some preferred more frequent sessions with more premeeting readings and self-assessments in fewer topics that were covered more longitudinally. A proposed example of a longitudinal topic was defining and refining existing mentoring relationships. Others found it useful to cover more ground with a potpourri of themes; they wanted to cover different knowledge, skills, and attitudes considered important for personal growth and career development, such as negotiation, leading teams, and managing conflict. We recommend the goals of the peer group be defined collaboratively at the beginning of new groups to respond to the needs of the group.

Third, junior faculty varied in how they viewed the goal of the program on a spectrum ranging from social support to mentorship. On one end of the spectrum, the program provided a safe venue for colleagues to convene periodically to discuss work challenges; this group found the support from peers to be helpful. On the other end, some found value in the coaching and mentoring from peers and the experienced facilitator that guided personal growth and career development.

Our pilot program has several limitations. This is a single-center program with a relatively small number of participants; thus, our experience may be unique to our institution and not representative of all academic hospital medicine programs. We also did not obtain any quantitative metrics of evaluation—mixed methods should be used in the future for more rigorous program evaluation. Finally, our peer mentoring model may not cover all domains of mentoring such as sponsorship for career advancement, provision of resources, and promotion of scholarship, though we mentioned an anecdote of scholarship that resulted from networking and redefining of goals that were facilitated through this program. Scholarship is certainly an important feature of academic medicine—other peer mentoring programs may consider forming groups based on research interests to address this gap. A tailored curriculum toward research and scholarship may garner more interest and benefit from participants interested in advancement of scholarship activities.

Overall, the field of hospital medicine is growing rapidly with junior faculty who need effective mentorship. Facilitated peer mentorship among small groups of junior faculty is a feasible and pragmatic mentorship model that can complement more traditional mentorship models. We discovered wide-ranging and contrasting experiences in our program, which suggests that peer mentorship is not a one-size-fits-all approach. However, facilitated peer mentorship can be a highly adaptable and alternative approach to mentorship for diverse groups of hospitalists, including general internal medicine, pediatrics, and other subspecialties. Future studies including multicenter, randomized trials comparing peer mentoring and traditional dyadic mentoring are needed. It is imperative for the field to investigate best practices in mentorship to sustain the rapid growth of hospital medicine and training the new generation of academic hospitalists.

Traditional mentorship models may not be adequate for academic hospitalists. The traditional dyadic mentorship model, in which a senior principal investigator and research mentee collaborate for career advancement, is well suited for basic science or clinical research. In contrast, areas of academic hospital medicine such as quality improvement, medical education, hospital operations, point-of-care ultrasound, and clinical expertise may be less suited to this traditional mentoring model. In addition, experienced mentors are limited and those available are often overcommitted or have inadequate time due to responsibilities with other leadership roles. Senior mentors may also be limited because of our specialty’s focus on clinical practice rather than longitudinal research or projects.⁹ There are other limitations of traditional mentorship that are applicable to all fields of academic medicine, including disparate goals, expectations, levels of commitment, and the inherent power differential between the mentor and mentee.¹⁰

In this perspective, we discuss our experience with implementing an alternative and complementary mentorship strategy called facilitated peer mentorship with junior faculty hospitalists in the Division of General Internal Medicine at New York–Presbyterian/Weill Cornell Medical Center.

In facilitated peer mentoring programs, faculty typically work collaboratively in groups of three to five with other faculty who are of similar rank, and a faculty member of a higher academic rank works with the group in meeting their scholarly goals.¹¹ The role of the facilitator is to ensure a safe and respectful learning environment, foster peer collaboration, and redirect the group to draw upon their own experiences. Each junior faculty member serves as both a mentor and mentee for each other with bidirectional feedback, guidance, and support in a group setting. This model emphasizes collaboration, peer networking, empowerment, and the development of personal awareness.¹⁰ A number of academic medical centers have used peer mentoring as a response to the challenges encountered in the traditional dyad model.¹² To our knowledge, the only published example of a peer mentoring model in academic hospital medicine is in the form of a research-in-progress conference.¹³ While this example addresses peer-mentored research, there is a gap in other areas of academic hospital medicine with mentoring needs—most of all in personal development and career satisfaction.

We piloted a 12-month facilitated peer mentoring program for new hospitalists. The goal of the program was for junior faculty hospitalists to develop a better understanding of their own identity and core values that would enable them to more confidently navigate career choices, enhance their work vitality and career satisfaction, and develop their potential for leadership roles in academic hospital medicine. Each year, a cohort of four to five incoming hospitalists from different backgrounds, interests, and experience were grouped with a more experienced colleague at an associate professor rank who expressed interest and was selected by our section chief to lead the program. The program was required for new hospitalists and consisted of six 90-minute sessions every two months. The attendance rate was 100% and was ensured by scheduling all sessions at the beginning of the academic year with dates agreed upon by all participants. An e-mail reminder was sent one week prior to each session. Each session had assigned readings and an agenda for discussions (see Table for details).

Our evaluation of the program after two years with two separate cohorts included qualitative feedback through an anonymous survey for participants; in addition, qualitative feedback was collected in a one-hour, in-person discussion and reflection with each cohort. We learned several lessons from the feedback we received from program participants. First, our impression was that the career experience of the junior faculty member had a significant impact on the perceived value of group meetings. For those who entered the hospitalist workforce immediately upon completing their terminal training in internal medicine, the exercise of considering different career versions of themselves had added value in promoting thinking outside-the-box for career opportunities within hospital medicine. Academic hospitalists and general internists more broadly, tend to have broad interests that fuel their passions but may also make it more difficult to define long-term goals. One junior faculty member paired her life interests in global medical education with building an international collaboration with other academic hospitalist programs; another faculty member gained confidence and expanded her network of collaborators by designing a research pilot study on hospitalist-initiated end-of-life discussions. In both cases, the junior faculty identified the facilitated peer mentoring program as a strong influence in finding these opportunities. Peer mentoring at the time of entry into the field of hospital medicine, when many have undefined career goals, can be helpful for navigating this issue at the start of a career. On the other hand, those who had already worked as a hospitalist for one or two years and joined the program found less value in career planning exercises.

Second, junior faculty differed in their desire for scope and depth of the curriculum. Some preferred more frequent sessions with more premeeting readings and self-assessments in fewer topics that were covered more longitudinally. A proposed example of a longitudinal topic was defining and refining existing mentoring relationships. Others found it useful to cover more ground with a potpourri of themes; they wanted to cover different knowledge, skills, and attitudes considered important for personal growth and career development, such as negotiation, leading teams, and managing conflict. We recommend the goals of the peer group be defined collaboratively at the beginning of new groups to respond to the needs of the group.

Third, junior faculty varied in how they viewed the goal of the program on a spectrum ranging from social support to mentorship. On one end of the spectrum, the program provided a safe venue for colleagues to convene periodically to discuss work challenges; this group found the support from peers to be helpful. On the other end, some found value in the coaching and mentoring from peers and the experienced facilitator that guided personal growth and career development.

Our pilot program has several limitations. This is a single-center program with a relatively small number of participants; thus, our experience may be unique to our institution and not representative of all academic hospital medicine programs. We also did not obtain any quantitative metrics of evaluation—mixed methods should be used in the future for more rigorous program evaluation. Finally, our peer mentoring model may not cover all domains of mentoring such as sponsorship for career advancement, provision of resources, and promotion of scholarship, though we mentioned an anecdote of scholarship that resulted from networking and redefining of goals that were facilitated through this program. Scholarship is certainly an important feature of academic medicine—other peer mentoring programs may consider forming groups based on research interests to address this gap. A tailored curriculum toward research and scholarship may garner more interest and benefit from participants interested in advancement of scholarship activities.

Overall, the field of hospital medicine is growing rapidly with junior faculty who need effective mentorship. Facilitated peer mentorship among small groups of junior faculty is a feasible and pragmatic mentorship model that can complement more traditional mentorship models. We discovered wide-ranging and contrasting experiences in our program, which suggests that peer mentorship is not a one-size-fits-all approach. However, facilitated peer mentorship can be a highly adaptable and alternative approach to mentorship for diverse groups of hospitalists, including general internal medicine, pediatrics, and other subspecialties. Future studies including multicenter, randomized trials comparing peer mentoring and traditional dyadic mentoring are needed. It is imperative for the field to investigate best practices in mentorship to sustain the rapid growth of hospital medicine and training the new generation of academic hospitalists.

Traditional mentorship models may not be adequate for academic hospitalists. The traditional dyadic mentorship model, in which a senior principal investigator and research mentee collaborate for career advancement, is well suited for basic science or clinical research. In contrast, areas of academic hospital medicine such as quality improvement, medical education, hospital operations, point-of-care ultrasound, and clinical expertise may be less suited to this traditional mentoring model. In addition, experienced mentors are limited and those available are often overcommitted or have inadequate time due to responsibilities with other leadership roles. Senior mentors may also be limited because of our specialty’s focus on clinical practice rather than longitudinal research or projects.⁹ There are other limitations of traditional mentorship that are applicable to all fields of academic medicine, including disparate goals, expectations, levels of commitment, and the inherent power differential between the mentor and mentee.¹⁰

In this perspective, we discuss our experience with implementing an alternative and complementary mentorship strategy called facilitated peer mentorship with junior faculty hospitalists in the Division of General Internal Medicine at New York–Presbyterian/Weill Cornell Medical Center.

In facilitated peer mentoring programs, faculty typically work collaboratively in groups of three to five with other faculty who are of similar rank, and a faculty member of a higher academic rank works with the group in meeting their scholarly goals.¹¹ The role of the facilitator is to ensure a safe and respectful learning environment, foster peer collaboration, and redirect the group to draw upon their own experiences. Each junior faculty member serves as both a mentor and mentee for each other with bidirectional feedback, guidance, and support in a group setting. This model emphasizes collaboration, peer networking, empowerment, and the development of personal awareness.¹⁰ A number of academic medical centers have used peer mentoring as a response to the challenges encountered in the traditional dyad model.¹² To our knowledge, the only published example of a peer mentoring model in academic hospital medicine is in the form of a research-in-progress conference.¹³ While this example addresses peer-mentored research, there is a gap in other areas of academic hospital medicine with mentoring needs—most of all in personal development and career satisfaction.

We piloted a 12-month facilitated peer mentoring program for new hospitalists. The goal of the program was for junior faculty hospitalists to develop a better understanding of their own identity and core values that would enable them to more confidently navigate career choices, enhance their work vitality and career satisfaction, and develop their potential for leadership roles in academic hospital medicine. Each year, a cohort of four to five incoming hospitalists from different backgrounds, interests, and experience were grouped with a more experienced colleague at an associate professor rank who expressed interest and was selected by our section chief to lead the program. The program was required for new hospitalists and consisted of six 90-minute sessions every two months. The attendance rate was 100% and was ensured by scheduling all sessions at the beginning of the academic year with dates agreed upon by all participants. An e-mail reminder was sent one week prior to each session. Each session had assigned readings and an agenda for discussions (see Table for details).

Our evaluation of the program after two years with two separate cohorts included qualitative feedback through an anonymous survey for participants; in addition, qualitative feedback was collected in a one-hour, in-person discussion and reflection with each cohort. We learned several lessons from the feedback we received from program participants. First, our impression was that the career experience of the junior faculty member had a significant impact on the perceived value of group meetings. For those who entered the hospitalist workforce immediately upon completing their terminal training in internal medicine, the exercise of considering different career versions of themselves had added value in promoting thinking outside-the-box for career opportunities within hospital medicine. Academic hospitalists and general internists more broadly, tend to have broad interests that fuel their passions but may also make it more difficult to define long-term goals. One junior faculty member paired her life interests in global medical education with building an international collaboration with other academic hospitalist programs; another faculty member gained confidence and expanded her network of collaborators by designing a research pilot study on hospitalist-initiated end-of-life discussions. In both cases, the junior faculty identified the facilitated peer mentoring program as a strong influence in finding these opportunities. Peer mentoring at the time of entry into the field of hospital medicine, when many have undefined career goals, can be helpful for navigating this issue at the start of a career. On the other hand, those who had already worked as a hospitalist for one or two years and joined the program found less value in career planning exercises.

Second, junior faculty differed in their desire for scope and depth of the curriculum. Some preferred more frequent sessions with more premeeting readings and self-assessments in fewer topics that were covered more longitudinally. A proposed example of a longitudinal topic was defining and refining existing mentoring relationships. Others found it useful to cover more ground with a potpourri of themes; they wanted to cover different knowledge, skills, and attitudes considered important for personal growth and career development, such as negotiation, leading teams, and managing conflict. We recommend the goals of the peer group be defined collaboratively at the beginning of new groups to respond to the needs of the group.

Third, junior faculty varied in how they viewed the goal of the program on a spectrum ranging from social support to mentorship. On one end of the spectrum, the program provided a safe venue for colleagues to convene periodically to discuss work challenges; this group found the support from peers to be helpful. On the other end, some found value in the coaching and mentoring from peers and the experienced facilitator that guided personal growth and career development.

Our pilot program has several limitations. This is a single-center program with a relatively small number of participants; thus, our experience may be unique to our institution and not representative of all academic hospital medicine programs. We also did not obtain any quantitative metrics of evaluation—mixed methods should be used in the future for more rigorous program evaluation. Finally, our peer mentoring model may not cover all domains of mentoring such as sponsorship for career advancement, provision of resources, and promotion of scholarship, though we mentioned an anecdote of scholarship that resulted from networking and redefining of goals that were facilitated through this program. Scholarship is certainly an important feature of academic medicine—other peer mentoring programs may consider forming groups based on research interests to address this gap. A tailored curriculum toward research and scholarship may garner more interest and benefit from participants interested in advancement of scholarship activities.

Overall, the field of hospital medicine is growing rapidly with junior faculty who need effective mentorship. Facilitated peer mentorship among small groups of junior faculty is a feasible and pragmatic mentorship model that can complement more traditional mentorship models. We discovered wide-ranging and contrasting experiences in our program, which suggests that peer mentorship is not a one-size-fits-all approach. However, facilitated peer mentorship can be a highly adaptable and alternative approach to mentorship for diverse groups of hospitalists, including general internal medicine, pediatrics, and other subspecialties. Future studies including multicenter, randomized trials comparing peer mentoring and traditional dyadic mentoring are needed. It is imperative for the field to investigate best practices in mentorship to sustain the rapid growth of hospital medicine and training the new generation of academic hospitalists.

“How much teaching time will I get in my first year on faculty?” Leaders at academic hospitalist programs know to expect this question from almost every applicant. We also know that we will be graded on our response; the more resident-covered service time, the better. For some applicants, this question is a key litmus test. Some prospective faculty choose to pursue academic hospital medicine because of their own experiences on the wards during residency. They recall the excitement of leading a team of interns and students under the wing of a seasoned attending, replete with chalk talks, clinical pearls, and inspired learners. Teaching time is more quantifiable than mentorship quality and academic opportunity, more important than salary and patient load for some, and more familiar than relative value unit expectations.

Over the past two decades, academic hospitalist programs have steadily grown,¹ but their teaching footprints have not.^2,3 Although historically some academic hospitalists spent almost 100% of their clinical time on teaching services, work hour rules and diversification of resident clinical time toward outpatient and subspecialty activities have decreased the amount of general medicine ward time for residents.² In addition, as academic medical centers broadened their clinical networks, inpatient volumes exceeded the capacity of teaching services. Finally, several large academic medical centers and healthcare networks are acquiring or building additional hospitals, increasing the number of medical beds that are staffed by hospitalists without residents.⁴

In our experience, as academic healthcare systems continue to grow and hospital medicine programs rapidly expand to meet clinical needs, the percentage of clinical time spent on a traditional ward teaching service continues to decrease. In several academic hospitalist programs, the majority of faculty effort is now devoted to direct care,⁵ with limited resident-covered ward time spread across a larger group of faculty. The 2018 State of Hospital Medicine Report suggests that our experience is not unique with academic programs caring for adults reporting that 31% of clinical work was on traditional ward teaching services, 16% on direct care services with intermittent learners, and 53% on nonteaching services.⁵

This current state of affairs raises a number of questions as follows:

• How can hospitalist program leaders take advantage of existing resident teaching opportunities?
• How should those teaching opportunities be allocated?
• What nontraditional teaching venues exist in academic medicine?
• How can faculty develop their teaching skills in an environment with limited traditional ward teaching time.

We believe that these changes require us to redefine what it means to be an academic hospitalist, both for existing faculty and for prospective faculty whose views of academic hospital medicine may have been shaped by role models seen only in their clinical teaching role.

Is reduced teaching time the new normal or will the pendulum swing back toward more resident teaching time for academic hospitalists? The former is likely the case. None of the current trends in medical education point to an expansion of residents in the inpatient setting. Although there may be some opportunities to assume general medicine attending time is currently covered by primary care physicians and subspecialists, in several programs, hospitalists already cover the overwhelming majority of general medicine teaching services.

Although there may be occasional opportunities for academic hospitalist programs to develop new teaching roles with residents or fellows (for example, by expanding to community sites with residency programs or to subspecialty teaching services, or by creating hospital medicine fellowships and resident or student electives), the reality is that we as hospitalists will need to adapt to direct care as the plurality of our work.

How should we allocate traditional teaching time among our faculty? Since it is a coveted—but relatively scarce—resource, teaching time should be allocated thoughtfully. Based on our collective experience, academic hospitalist groups have taken a variety of approaches to this challenge, including forming separate clinical groups at the same institution (a teaching faculty group and a nonteaching group),⁶ requiring all hospitalists to do some amount of direct care to facilitate distribution of teaching time or having merit or seniority-based teaching time allocation (based on teaching evaluations, formal teaching roles such as program director status, or years on faculty).

Each approach to assigning teaching time has its challenges. Hospitalist leaders must manage these issues through transparency about the selection process for teaching rotations and open discussion of teaching evaluations with faculty. It is also critical that the recruitment process set appropriate expectations for faculty candidates. Highlighting academic opportunities outside of teaching residents, including leadership roles, quality improvement work, and research, may encourage applicants and current hospitalists to explore more varied career trajectories. Hospitalists focusing on these other paths may elect to have less teaching time, freeing up opportunities for dedicated clinician educators.

What other ward-based teaching opportunities might be available for academic hospitalists who do not have the opportunity to attend on traditional resident teaching teams? As supervisory requirements for residents have been strengthened, expansion of teaching into the evening and overnight hours to supervise new admissions to the teaching services has been one approach to augment teaching footprints.^7,8

In addition, nontraditional teaching teams such as attending/intern teams (without a supervising resident) or attending/subintern (fourth-year medical student) teams have been developed at some institutions.⁹ Although allowing for additional exposure to learners, these models require a more hands-on approach than traditional teaching teams, particularly at the start of the academic year. Finally, as hospitalist teams have grown to include advanced practice providers (APPs), some programs have established formal teaching programs to address professional development needs of these healthcare professionals.^10,11

How do we help junior faculty who have the potential to be talented educators succeed in teaching when they have limited opportunities to engage with residents on clinical services? One approach is to encourage hospitalists to participate in resident didactic sessions such as “morning report” and noon conference. Another approach is to focus on teaching other learners. For example, several academic medical centers provide opportunities for hospitalists to engage in student teaching, either on the wards or via classroom instruction. In addition, as mentioned previously, APPs who are new to hospital medicine are an engaged audience and represent an opportunity for hospitalist educators to utilize and hone their teaching skills. Finally, organizing lectures for nursing colleagues is another way for the faculty to practice “chalk talks” and develop teaching portfolios.

Hospitalists can also leverage their expertise to build systems in which academic hospitalists are teaching each other, creating a culture of continuous learning. These activities may include case conferences, morbidity and mortality conferences, journal clubs, clinical topic updates developed by and for hospitalists, simulation exercises, and other group learning sessions. Giving hospitalists the opportunity to teach each other allows for professional growth that is not dependent on the presence of traditional learners.

Philosophically, a key question is “What makes ‘academic’ academic?” Traditionally, academic hospitalist positions were synonymous with resident teaching or, for a small number of academic hospitalists, significant funded research. In an era where teaching residents may no longer be part of the job description for many hospitalists at academic medical centers, what distinguishes these positions from 100% clinical positions and what are the implications for academic hospital medicine?

Although data regarding why hospitalists seek “nonteaching” positions at academic medical centers are lacking, we believe that these jobs remain popular due to opportunities that are perceived to be unique to academic medical centers. These include more flexible scheduling (academic programs may be less likely to have seven-on/seven-off schedules), exposure to research and cutting-edge technology, opportunities to care for tertiary and quaternary care patients, collaboration with academic peers and experts in the field, and interaction with a range of learners, including medical, pharmacy, advanced practitioner, and other students.

Understanding the motivation of candidates who apply for academic hospital medicine positions—aside from supervising/teaching residents—will be an important goal for academic hospitalist leaders to ensure future success in staffing growing programs and creating sustainable academic hospitalist careers. As resident teaching time decreases, implementing robust faculty or professional development programs to address the broader interests and needs of academic hospitalist faculty will be increasingly important. Sehgal et al. described one such program for faculty development,¹² and a more recent paper outlines a faculty development program focused on quality improvement and patient safety.¹³ These types of programs provide opportunities for academic hospitalists to engage in academic pursuits that are independent of residency programs.

Therefore, what do we tell the eager faculty applicant? First, we should not hide from the honest answer, ie, new faculty may not get as much resident teaching time as they would like or expect. Although we want hospitalists to maintain integral involvement in residency training programs, we also want to build a culture of clinical excellence, scholarship, and continuous learning that is not dependent on directly teaching residents. We should highlight the unique opportunities of academic hospital medicine, including teaching other learners, caring for tertiary/quaternary care patients, working with colleagues who are leaders in their field, and engaging in research and quality improvement work. By capitalizing on these opportunities, we can actively redefine what makes “academic” academic and ensure that we sustain academic hospital medicine as a desirable and rewarding career.

Disclosures

The authors have nothing to disclose.

“How much teaching time will I get in my first year on faculty?” Leaders at academic hospitalist programs know to expect this question from almost every applicant. We also know that we will be graded on our response; the more resident-covered service time, the better. For some applicants, this question is a key litmus test. Some prospective faculty choose to pursue academic hospital medicine because of their own experiences on the wards during residency. They recall the excitement of leading a team of interns and students under the wing of a seasoned attending, replete with chalk talks, clinical pearls, and inspired learners. Teaching time is more quantifiable than mentorship quality and academic opportunity, more important than salary and patient load for some, and more familiar than relative value unit expectations.

Over the past two decades, academic hospitalist programs have steadily grown,¹ but their teaching footprints have not.^2,3 Although historically some academic hospitalists spent almost 100% of their clinical time on teaching services, work hour rules and diversification of resident clinical time toward outpatient and subspecialty activities have decreased the amount of general medicine ward time for residents.² In addition, as academic medical centers broadened their clinical networks, inpatient volumes exceeded the capacity of teaching services. Finally, several large academic medical centers and healthcare networks are acquiring or building additional hospitals, increasing the number of medical beds that are staffed by hospitalists without residents.⁴

In our experience, as academic healthcare systems continue to grow and hospital medicine programs rapidly expand to meet clinical needs, the percentage of clinical time spent on a traditional ward teaching service continues to decrease. In several academic hospitalist programs, the majority of faculty effort is now devoted to direct care,⁵ with limited resident-covered ward time spread across a larger group of faculty. The 2018 State of Hospital Medicine Report suggests that our experience is not unique with academic programs caring for adults reporting that 31% of clinical work was on traditional ward teaching services, 16% on direct care services with intermittent learners, and 53% on nonteaching services.⁵

This current state of affairs raises a number of questions as follows:

• How can hospitalist program leaders take advantage of existing resident teaching opportunities?
• How should those teaching opportunities be allocated?
• What nontraditional teaching venues exist in academic medicine?
• How can faculty develop their teaching skills in an environment with limited traditional ward teaching time.

We believe that these changes require us to redefine what it means to be an academic hospitalist, both for existing faculty and for prospective faculty whose views of academic hospital medicine may have been shaped by role models seen only in their clinical teaching role.

Is reduced teaching time the new normal or will the pendulum swing back toward more resident teaching time for academic hospitalists? The former is likely the case. None of the current trends in medical education point to an expansion of residents in the inpatient setting. Although there may be some opportunities to assume general medicine attending time is currently covered by primary care physicians and subspecialists, in several programs, hospitalists already cover the overwhelming majority of general medicine teaching services.

Although there may be occasional opportunities for academic hospitalist programs to develop new teaching roles with residents or fellows (for example, by expanding to community sites with residency programs or to subspecialty teaching services, or by creating hospital medicine fellowships and resident or student electives), the reality is that we as hospitalists will need to adapt to direct care as the plurality of our work.

How should we allocate traditional teaching time among our faculty? Since it is a coveted—but relatively scarce—resource, teaching time should be allocated thoughtfully. Based on our collective experience, academic hospitalist groups have taken a variety of approaches to this challenge, including forming separate clinical groups at the same institution (a teaching faculty group and a nonteaching group),⁶ requiring all hospitalists to do some amount of direct care to facilitate distribution of teaching time or having merit or seniority-based teaching time allocation (based on teaching evaluations, formal teaching roles such as program director status, or years on faculty).

Each approach to assigning teaching time has its challenges. Hospitalist leaders must manage these issues through transparency about the selection process for teaching rotations and open discussion of teaching evaluations with faculty. It is also critical that the recruitment process set appropriate expectations for faculty candidates. Highlighting academic opportunities outside of teaching residents, including leadership roles, quality improvement work, and research, may encourage applicants and current hospitalists to explore more varied career trajectories. Hospitalists focusing on these other paths may elect to have less teaching time, freeing up opportunities for dedicated clinician educators.

What other ward-based teaching opportunities might be available for academic hospitalists who do not have the opportunity to attend on traditional resident teaching teams? As supervisory requirements for residents have been strengthened, expansion of teaching into the evening and overnight hours to supervise new admissions to the teaching services has been one approach to augment teaching footprints.^7,8

In addition, nontraditional teaching teams such as attending/intern teams (without a supervising resident) or attending/subintern (fourth-year medical student) teams have been developed at some institutions.⁹ Although allowing for additional exposure to learners, these models require a more hands-on approach than traditional teaching teams, particularly at the start of the academic year. Finally, as hospitalist teams have grown to include advanced practice providers (APPs), some programs have established formal teaching programs to address professional development needs of these healthcare professionals.^10,11

How do we help junior faculty who have the potential to be talented educators succeed in teaching when they have limited opportunities to engage with residents on clinical services? One approach is to encourage hospitalists to participate in resident didactic sessions such as “morning report” and noon conference. Another approach is to focus on teaching other learners. For example, several academic medical centers provide opportunities for hospitalists to engage in student teaching, either on the wards or via classroom instruction. In addition, as mentioned previously, APPs who are new to hospital medicine are an engaged audience and represent an opportunity for hospitalist educators to utilize and hone their teaching skills. Finally, organizing lectures for nursing colleagues is another way for the faculty to practice “chalk talks” and develop teaching portfolios.

Hospitalists can also leverage their expertise to build systems in which academic hospitalists are teaching each other, creating a culture of continuous learning. These activities may include case conferences, morbidity and mortality conferences, journal clubs, clinical topic updates developed by and for hospitalists, simulation exercises, and other group learning sessions. Giving hospitalists the opportunity to teach each other allows for professional growth that is not dependent on the presence of traditional learners.

Philosophically, a key question is “What makes ‘academic’ academic?” Traditionally, academic hospitalist positions were synonymous with resident teaching or, for a small number of academic hospitalists, significant funded research. In an era where teaching residents may no longer be part of the job description for many hospitalists at academic medical centers, what distinguishes these positions from 100% clinical positions and what are the implications for academic hospital medicine?

Although data regarding why hospitalists seek “nonteaching” positions at academic medical centers are lacking, we believe that these jobs remain popular due to opportunities that are perceived to be unique to academic medical centers. These include more flexible scheduling (academic programs may be less likely to have seven-on/seven-off schedules), exposure to research and cutting-edge technology, opportunities to care for tertiary and quaternary care patients, collaboration with academic peers and experts in the field, and interaction with a range of learners, including medical, pharmacy, advanced practitioner, and other students.

Understanding the motivation of candidates who apply for academic hospital medicine positions—aside from supervising/teaching residents—will be an important goal for academic hospitalist leaders to ensure future success in staffing growing programs and creating sustainable academic hospitalist careers. As resident teaching time decreases, implementing robust faculty or professional development programs to address the broader interests and needs of academic hospitalist faculty will be increasingly important. Sehgal et al. described one such program for faculty development,¹² and a more recent paper outlines a faculty development program focused on quality improvement and patient safety.¹³ These types of programs provide opportunities for academic hospitalists to engage in academic pursuits that are independent of residency programs.

Therefore, what do we tell the eager faculty applicant? First, we should not hide from the honest answer, ie, new faculty may not get as much resident teaching time as they would like or expect. Although we want hospitalists to maintain integral involvement in residency training programs, we also want to build a culture of clinical excellence, scholarship, and continuous learning that is not dependent on directly teaching residents. We should highlight the unique opportunities of academic hospital medicine, including teaching other learners, caring for tertiary/quaternary care patients, working with colleagues who are leaders in their field, and engaging in research and quality improvement work. By capitalizing on these opportunities, we can actively redefine what makes “academic” academic and ensure that we sustain academic hospital medicine as a desirable and rewarding career.

Disclosures

The authors have nothing to disclose.

“How much teaching time will I get in my first year on faculty?” Leaders at academic hospitalist programs know to expect this question from almost every applicant. We also know that we will be graded on our response; the more resident-covered service time, the better. For some applicants, this question is a key litmus test. Some prospective faculty choose to pursue academic hospital medicine because of their own experiences on the wards during residency. They recall the excitement of leading a team of interns and students under the wing of a seasoned attending, replete with chalk talks, clinical pearls, and inspired learners. Teaching time is more quantifiable than mentorship quality and academic opportunity, more important than salary and patient load for some, and more familiar than relative value unit expectations.

Over the past two decades, academic hospitalist programs have steadily grown,¹ but their teaching footprints have not.^2,3 Although historically some academic hospitalists spent almost 100% of their clinical time on teaching services, work hour rules and diversification of resident clinical time toward outpatient and subspecialty activities have decreased the amount of general medicine ward time for residents.² In addition, as academic medical centers broadened their clinical networks, inpatient volumes exceeded the capacity of teaching services. Finally, several large academic medical centers and healthcare networks are acquiring or building additional hospitals, increasing the number of medical beds that are staffed by hospitalists without residents.⁴

In our experience, as academic healthcare systems continue to grow and hospital medicine programs rapidly expand to meet clinical needs, the percentage of clinical time spent on a traditional ward teaching service continues to decrease. In several academic hospitalist programs, the majority of faculty effort is now devoted to direct care,⁵ with limited resident-covered ward time spread across a larger group of faculty. The 2018 State of Hospital Medicine Report suggests that our experience is not unique with academic programs caring for adults reporting that 31% of clinical work was on traditional ward teaching services, 16% on direct care services with intermittent learners, and 53% on nonteaching services.⁵

This current state of affairs raises a number of questions as follows:

• How can hospitalist program leaders take advantage of existing resident teaching opportunities?
• How should those teaching opportunities be allocated?
• What nontraditional teaching venues exist in academic medicine?
• How can faculty develop their teaching skills in an environment with limited traditional ward teaching time.

We believe that these changes require us to redefine what it means to be an academic hospitalist, both for existing faculty and for prospective faculty whose views of academic hospital medicine may have been shaped by role models seen only in their clinical teaching role.

Is reduced teaching time the new normal or will the pendulum swing back toward more resident teaching time for academic hospitalists? The former is likely the case. None of the current trends in medical education point to an expansion of residents in the inpatient setting. Although there may be some opportunities to assume general medicine attending time is currently covered by primary care physicians and subspecialists, in several programs, hospitalists already cover the overwhelming majority of general medicine teaching services.

Although there may be occasional opportunities for academic hospitalist programs to develop new teaching roles with residents or fellows (for example, by expanding to community sites with residency programs or to subspecialty teaching services, or by creating hospital medicine fellowships and resident or student electives), the reality is that we as hospitalists will need to adapt to direct care as the plurality of our work.

How should we allocate traditional teaching time among our faculty? Since it is a coveted—but relatively scarce—resource, teaching time should be allocated thoughtfully. Based on our collective experience, academic hospitalist groups have taken a variety of approaches to this challenge, including forming separate clinical groups at the same institution (a teaching faculty group and a nonteaching group),⁶ requiring all hospitalists to do some amount of direct care to facilitate distribution of teaching time or having merit or seniority-based teaching time allocation (based on teaching evaluations, formal teaching roles such as program director status, or years on faculty).

Each approach to assigning teaching time has its challenges. Hospitalist leaders must manage these issues through transparency about the selection process for teaching rotations and open discussion of teaching evaluations with faculty. It is also critical that the recruitment process set appropriate expectations for faculty candidates. Highlighting academic opportunities outside of teaching residents, including leadership roles, quality improvement work, and research, may encourage applicants and current hospitalists to explore more varied career trajectories. Hospitalists focusing on these other paths may elect to have less teaching time, freeing up opportunities for dedicated clinician educators.

What other ward-based teaching opportunities might be available for academic hospitalists who do not have the opportunity to attend on traditional resident teaching teams? As supervisory requirements for residents have been strengthened, expansion of teaching into the evening and overnight hours to supervise new admissions to the teaching services has been one approach to augment teaching footprints.^7,8

In addition, nontraditional teaching teams such as attending/intern teams (without a supervising resident) or attending/subintern (fourth-year medical student) teams have been developed at some institutions.⁹ Although allowing for additional exposure to learners, these models require a more hands-on approach than traditional teaching teams, particularly at the start of the academic year. Finally, as hospitalist teams have grown to include advanced practice providers (APPs), some programs have established formal teaching programs to address professional development needs of these healthcare professionals.^10,11

How do we help junior faculty who have the potential to be talented educators succeed in teaching when they have limited opportunities to engage with residents on clinical services? One approach is to encourage hospitalists to participate in resident didactic sessions such as “morning report” and noon conference. Another approach is to focus on teaching other learners. For example, several academic medical centers provide opportunities for hospitalists to engage in student teaching, either on the wards or via classroom instruction. In addition, as mentioned previously, APPs who are new to hospital medicine are an engaged audience and represent an opportunity for hospitalist educators to utilize and hone their teaching skills. Finally, organizing lectures for nursing colleagues is another way for the faculty to practice “chalk talks” and develop teaching portfolios.

Hospitalists can also leverage their expertise to build systems in which academic hospitalists are teaching each other, creating a culture of continuous learning. These activities may include case conferences, morbidity and mortality conferences, journal clubs, clinical topic updates developed by and for hospitalists, simulation exercises, and other group learning sessions. Giving hospitalists the opportunity to teach each other allows for professional growth that is not dependent on the presence of traditional learners.

Philosophically, a key question is “What makes ‘academic’ academic?” Traditionally, academic hospitalist positions were synonymous with resident teaching or, for a small number of academic hospitalists, significant funded research. In an era where teaching residents may no longer be part of the job description for many hospitalists at academic medical centers, what distinguishes these positions from 100% clinical positions and what are the implications for academic hospital medicine?

Although data regarding why hospitalists seek “nonteaching” positions at academic medical centers are lacking, we believe that these jobs remain popular due to opportunities that are perceived to be unique to academic medical centers. These include more flexible scheduling (academic programs may be less likely to have seven-on/seven-off schedules), exposure to research and cutting-edge technology, opportunities to care for tertiary and quaternary care patients, collaboration with academic peers and experts in the field, and interaction with a range of learners, including medical, pharmacy, advanced practitioner, and other students.

Understanding the motivation of candidates who apply for academic hospital medicine positions—aside from supervising/teaching residents—will be an important goal for academic hospitalist leaders to ensure future success in staffing growing programs and creating sustainable academic hospitalist careers. As resident teaching time decreases, implementing robust faculty or professional development programs to address the broader interests and needs of academic hospitalist faculty will be increasingly important. Sehgal et al. described one such program for faculty development,¹² and a more recent paper outlines a faculty development program focused on quality improvement and patient safety.¹³ These types of programs provide opportunities for academic hospitalists to engage in academic pursuits that are independent of residency programs.

Therefore, what do we tell the eager faculty applicant? First, we should not hide from the honest answer, ie, new faculty may not get as much resident teaching time as they would like or expect. Although we want hospitalists to maintain integral involvement in residency training programs, we also want to build a culture of clinical excellence, scholarship, and continuous learning that is not dependent on directly teaching residents. We should highlight the unique opportunities of academic hospital medicine, including teaching other learners, caring for tertiary/quaternary care patients, working with colleagues who are leaders in their field, and engaging in research and quality improvement work. By capitalizing on these opportunities, we can actively redefine what makes “academic” academic and ensure that we sustain academic hospital medicine as a desirable and rewarding career.

Disclosures

The authors have nothing to disclose.

“I don’t think she’ll ever make it home again.”

I stood at the nursing station with two staff nurses from our medical ward. The patient, a woman with metastatic cancer and acute respiratory failure, had just arrived by a medical helicopter from an out-of-state community hospital. At the previous hospital, days had stretched into weeks, and she was not getting better. Limited documentation told us that the patient’s family sought further options at our facility. Beyond that, we knew little about the conversations that had transpired. The transfer had been arranged and off she went, arriving on our helipad in worsening respiratory distress, now needing a higher level of supplemental oxygen and teetering on the edge of endotracheal intubation. Above all, she was extremely uncomfortable from shortness of breath, and an urgent palliative care consult was placed a few hours after she touched down.

I arrived at the bedside to meet the patient and family. In these circumstances, I often feel that a palliative care consult is not the miracle that patients seek, but the grim consolation prize behind door two of a tragic and exhausting game show of a hospital transfer. I read the family’s dismayed facial expressions as they gazed at my badge reading “Palliative Care” and imagined that they would have preferred a different answer to their question that led them here: “Is this all that can be done?”

The hope of patients and families is a precious thing. As a palliative care physician, I recognize that my role is never to take away hope but rather reframe the wish for recovery into the realm of the achievable. Some people can pivot when the hospital transfer happens. They feel that they have “done all they could” and searched the earth for the reversal of their medical circumstances. I empathize with the wish to try everything and respect the motivation that lies behind it. I also see the cost of chasing hope.

In 2017, 1.5 million patients were transferred, comprising 3.5% of all hospital admissions.¹ Although the majority of hospital transfers are medically appropriate and hold the possibility of treatment options unavailable at smaller facilities, there are also significant drawbacks. Transfers have been identified as risky times for adverse events, are often expensive, and are associated with higher mortality and longer length of stay.² There are often lapses in documentation and provider communication, and handoff practices vary widely between hospitals.³ Some transferred seriously ill patients become functionally trapped in the accepting hospital. Patients arrive too sick to undergo any meaningful disease-directed therapy and too medically tenuous to return to their home community.

When patients and families seem overly hopeful about what a transfer might provide, the request for transfer may indicate a deeper need for empathic understanding. Clinical conversations about “what can be done” typically focus on medical aspects and often miss a critical element—a complete exploration of a seriously ill patient’s prognostic awareness.

In palliative care, we use the term prognostic awareness to define patients’ dynamic understanding of their prognosis in terms of likely longevity and quality of life. Accurate prognostic awareness—where there is concordance between a patient’s worries and the medical facts as understood by their treatment team—has been associated with enhanced quality of life and mood when patients have enough emotional reserve to actively cope with the illness; for example, by reframing things in a positive light.^4,5 However, when patients are struggling to cope, talking about the prognosis is hard for patients and for their clinicians, who often accurately perceive their patient’s struggle and delay conversations, hoping that more time will help their patient better adapt and prepare to talk about it.^6,7 However, delaying conversations makes it even harder for patients and families to develop accurate prognostic awareness, leaving them unprepared when medical decisions arise.⁸ Such delays have a particularly strong impact in nononcology care, where a more unpredictable illness trajectory makes it even harder for patients to understand and prepare for what might happen.

When seriously ill patients and families consider transfer to a tertiary medical center in a situation of medical crisis, it can be a good time to pause. Palliative care specialists are trained to communicate around these difficult points of transition, but generalist clinicians already involved in the patient’s care can also sensitively explore patients’ prognostic awareness as it relates to the hospital transfer.⁹ In the Table, The phrases mentioned suggest language that is helpful in broaching such discussions, which assesses the patient’s illness understanding, hopes, and worries. Asking about patients’ hopes for their illness enables clinicians to quickly know some of their most important priorities. Giving patients the permission to be future-oriented and positive also supports them to cope in these challenging conversations. Asking patients to identify two or three hopes places their most optimistic hopes within a larger context and can lead to a discussion of the potential tradeoffs of the transfer.¹⁰ For example, the hope for a little more time from treatments available through transfer may be at odds with the hope to spend as much time as possible with family. Once the patient’s hopes are better understood, the clinician can then ask about worries. Most seriously ill patients are deeply (often silently) worried about the future, and when asked, can articulate worries about dying that can be the foundation for an honest conversation about the likely course of the hospital transfer.

With empathic assessment, several patients can speak honestly with their clinicians about their illness, including the pros and cons of hospital transfer. However, some continue to struggle, often asking clinicians to remain positive and not endorsing any worry. We describe these patients as having low prognostic awareness.¹¹ With such patients, palliative care expertise may be needed to ensure that patients and their families have the information they need to engage in informed medical decision-making. There are emerging models for distance palliative care integration, which may be helpful in these situations.¹² If these technologies became common in practice, frontline clinicians may increasingly find virtual consultation helpful in working with patients to develop more accurate prognostic awareness. There is also the possibility of clinician-to-clinician electronic consultation, or peer coaching, where the patient is not seen directly by the consultant, but expert advice is offered to the local provider.¹³ Although both these innovations offer service that currently may not be available in certain care settings, in-person consultation remains the gold standard. If a nuanced discussion cannot be had, palliative care expertise may be the reason for transfer.

Back at our hospital, I met with the patient and her partner. There were tradeoffs to be made and hard truths to be acknowledged. In this unfamiliar place, with caregivers she had met just hours before, the patient changed her resuscitation order to allow for a natural death. She passed away later that evening, surrounded by her immediate family but far away from the community that had held her throughout her illness. I reflect on the loss that can come with choosing “everything” when efforts are often better spent on ensuring comfort. Although hospital transfer is often the right answer for seriously ill patients seeking diagnostic and therapeutic options unavailable at their home medical centers, the question should also be an impetus for a nuanced assessment of patients’ prognostic awareness to prepare patients if things do not go as hoped or to enlist palliative care expertise for those struggling to cope. As there is a workforce shortage of palliative care providers, particularly in smaller and rural American hospitals, frontline hospitalist clinicians may find themselves increasingly playing a critical role in discussions where transfer is considered. By assessing patients’ prognostic awareness through thoughtful, compassionate inquiry in these moments of transition, we can support informed medical decision-making.

“I don’t think she’ll ever make it home again.”

I stood at the nursing station with two staff nurses from our medical ward. The patient, a woman with metastatic cancer and acute respiratory failure, had just arrived by a medical helicopter from an out-of-state community hospital. At the previous hospital, days had stretched into weeks, and she was not getting better. Limited documentation told us that the patient’s family sought further options at our facility. Beyond that, we knew little about the conversations that had transpired. The transfer had been arranged and off she went, arriving on our helipad in worsening respiratory distress, now needing a higher level of supplemental oxygen and teetering on the edge of endotracheal intubation. Above all, she was extremely uncomfortable from shortness of breath, and an urgent palliative care consult was placed a few hours after she touched down.

I arrived at the bedside to meet the patient and family. In these circumstances, I often feel that a palliative care consult is not the miracle that patients seek, but the grim consolation prize behind door two of a tragic and exhausting game show of a hospital transfer. I read the family’s dismayed facial expressions as they gazed at my badge reading “Palliative Care” and imagined that they would have preferred a different answer to their question that led them here: “Is this all that can be done?”

The hope of patients and families is a precious thing. As a palliative care physician, I recognize that my role is never to take away hope but rather reframe the wish for recovery into the realm of the achievable. Some people can pivot when the hospital transfer happens. They feel that they have “done all they could” and searched the earth for the reversal of their medical circumstances. I empathize with the wish to try everything and respect the motivation that lies behind it. I also see the cost of chasing hope.

In 2017, 1.5 million patients were transferred, comprising 3.5% of all hospital admissions.¹ Although the majority of hospital transfers are medically appropriate and hold the possibility of treatment options unavailable at smaller facilities, there are also significant drawbacks. Transfers have been identified as risky times for adverse events, are often expensive, and are associated with higher mortality and longer length of stay.² There are often lapses in documentation and provider communication, and handoff practices vary widely between hospitals.³ Some transferred seriously ill patients become functionally trapped in the accepting hospital. Patients arrive too sick to undergo any meaningful disease-directed therapy and too medically tenuous to return to their home community.

When patients and families seem overly hopeful about what a transfer might provide, the request for transfer may indicate a deeper need for empathic understanding. Clinical conversations about “what can be done” typically focus on medical aspects and often miss a critical element—a complete exploration of a seriously ill patient’s prognostic awareness.

In palliative care, we use the term prognostic awareness to define patients’ dynamic understanding of their prognosis in terms of likely longevity and quality of life. Accurate prognostic awareness—where there is concordance between a patient’s worries and the medical facts as understood by their treatment team—has been associated with enhanced quality of life and mood when patients have enough emotional reserve to actively cope with the illness; for example, by reframing things in a positive light.^4,5 However, when patients are struggling to cope, talking about the prognosis is hard for patients and for their clinicians, who often accurately perceive their patient’s struggle and delay conversations, hoping that more time will help their patient better adapt and prepare to talk about it.^6,7 However, delaying conversations makes it even harder for patients and families to develop accurate prognostic awareness, leaving them unprepared when medical decisions arise.⁸ Such delays have a particularly strong impact in nononcology care, where a more unpredictable illness trajectory makes it even harder for patients to understand and prepare for what might happen.

When seriously ill patients and families consider transfer to a tertiary medical center in a situation of medical crisis, it can be a good time to pause. Palliative care specialists are trained to communicate around these difficult points of transition, but generalist clinicians already involved in the patient’s care can also sensitively explore patients’ prognostic awareness as it relates to the hospital transfer.⁹ In the Table, The phrases mentioned suggest language that is helpful in broaching such discussions, which assesses the patient’s illness understanding, hopes, and worries. Asking about patients’ hopes for their illness enables clinicians to quickly know some of their most important priorities. Giving patients the permission to be future-oriented and positive also supports them to cope in these challenging conversations. Asking patients to identify two or three hopes places their most optimistic hopes within a larger context and can lead to a discussion of the potential tradeoffs of the transfer.¹⁰ For example, the hope for a little more time from treatments available through transfer may be at odds with the hope to spend as much time as possible with family. Once the patient’s hopes are better understood, the clinician can then ask about worries. Most seriously ill patients are deeply (often silently) worried about the future, and when asked, can articulate worries about dying that can be the foundation for an honest conversation about the likely course of the hospital transfer.

With empathic assessment, several patients can speak honestly with their clinicians about their illness, including the pros and cons of hospital transfer. However, some continue to struggle, often asking clinicians to remain positive and not endorsing any worry. We describe these patients as having low prognostic awareness.¹¹ With such patients, palliative care expertise may be needed to ensure that patients and their families have the information they need to engage in informed medical decision-making. There are emerging models for distance palliative care integration, which may be helpful in these situations.¹² If these technologies became common in practice, frontline clinicians may increasingly find virtual consultation helpful in working with patients to develop more accurate prognostic awareness. There is also the possibility of clinician-to-clinician electronic consultation, or peer coaching, where the patient is not seen directly by the consultant, but expert advice is offered to the local provider.¹³ Although both these innovations offer service that currently may not be available in certain care settings, in-person consultation remains the gold standard. If a nuanced discussion cannot be had, palliative care expertise may be the reason for transfer.

Back at our hospital, I met with the patient and her partner. There were tradeoffs to be made and hard truths to be acknowledged. In this unfamiliar place, with caregivers she had met just hours before, the patient changed her resuscitation order to allow for a natural death. She passed away later that evening, surrounded by her immediate family but far away from the community that had held her throughout her illness. I reflect on the loss that can come with choosing “everything” when efforts are often better spent on ensuring comfort. Although hospital transfer is often the right answer for seriously ill patients seeking diagnostic and therapeutic options unavailable at their home medical centers, the question should also be an impetus for a nuanced assessment of patients’ prognostic awareness to prepare patients if things do not go as hoped or to enlist palliative care expertise for those struggling to cope. As there is a workforce shortage of palliative care providers, particularly in smaller and rural American hospitals, frontline hospitalist clinicians may find themselves increasingly playing a critical role in discussions where transfer is considered. By assessing patients’ prognostic awareness through thoughtful, compassionate inquiry in these moments of transition, we can support informed medical decision-making.

“I don’t think she’ll ever make it home again.”

I stood at the nursing station with two staff nurses from our medical ward. The patient, a woman with metastatic cancer and acute respiratory failure, had just arrived by a medical helicopter from an out-of-state community hospital. At the previous hospital, days had stretched into weeks, and she was not getting better. Limited documentation told us that the patient’s family sought further options at our facility. Beyond that, we knew little about the conversations that had transpired. The transfer had been arranged and off she went, arriving on our helipad in worsening respiratory distress, now needing a higher level of supplemental oxygen and teetering on the edge of endotracheal intubation. Above all, she was extremely uncomfortable from shortness of breath, and an urgent palliative care consult was placed a few hours after she touched down.

I arrived at the bedside to meet the patient and family. In these circumstances, I often feel that a palliative care consult is not the miracle that patients seek, but the grim consolation prize behind door two of a tragic and exhausting game show of a hospital transfer. I read the family’s dismayed facial expressions as they gazed at my badge reading “Palliative Care” and imagined that they would have preferred a different answer to their question that led them here: “Is this all that can be done?”

The hope of patients and families is a precious thing. As a palliative care physician, I recognize that my role is never to take away hope but rather reframe the wish for recovery into the realm of the achievable. Some people can pivot when the hospital transfer happens. They feel that they have “done all they could” and searched the earth for the reversal of their medical circumstances. I empathize with the wish to try everything and respect the motivation that lies behind it. I also see the cost of chasing hope.

In 2017, 1.5 million patients were transferred, comprising 3.5% of all hospital admissions.¹ Although the majority of hospital transfers are medically appropriate and hold the possibility of treatment options unavailable at smaller facilities, there are also significant drawbacks. Transfers have been identified as risky times for adverse events, are often expensive, and are associated with higher mortality and longer length of stay.² There are often lapses in documentation and provider communication, and handoff practices vary widely between hospitals.³ Some transferred seriously ill patients become functionally trapped in the accepting hospital. Patients arrive too sick to undergo any meaningful disease-directed therapy and too medically tenuous to return to their home community.

When patients and families seem overly hopeful about what a transfer might provide, the request for transfer may indicate a deeper need for empathic understanding. Clinical conversations about “what can be done” typically focus on medical aspects and often miss a critical element—a complete exploration of a seriously ill patient’s prognostic awareness.

In palliative care, we use the term prognostic awareness to define patients’ dynamic understanding of their prognosis in terms of likely longevity and quality of life. Accurate prognostic awareness—where there is concordance between a patient’s worries and the medical facts as understood by their treatment team—has been associated with enhanced quality of life and mood when patients have enough emotional reserve to actively cope with the illness; for example, by reframing things in a positive light.^4,5 However, when patients are struggling to cope, talking about the prognosis is hard for patients and for their clinicians, who often accurately perceive their patient’s struggle and delay conversations, hoping that more time will help their patient better adapt and prepare to talk about it.^6,7 However, delaying conversations makes it even harder for patients and families to develop accurate prognostic awareness, leaving them unprepared when medical decisions arise.⁸ Such delays have a particularly strong impact in nononcology care, where a more unpredictable illness trajectory makes it even harder for patients to understand and prepare for what might happen.

When seriously ill patients and families consider transfer to a tertiary medical center in a situation of medical crisis, it can be a good time to pause. Palliative care specialists are trained to communicate around these difficult points of transition, but generalist clinicians already involved in the patient’s care can also sensitively explore patients’ prognostic awareness as it relates to the hospital transfer.⁹ In the Table, The phrases mentioned suggest language that is helpful in broaching such discussions, which assesses the patient’s illness understanding, hopes, and worries. Asking about patients’ hopes for their illness enables clinicians to quickly know some of their most important priorities. Giving patients the permission to be future-oriented and positive also supports them to cope in these challenging conversations. Asking patients to identify two or three hopes places their most optimistic hopes within a larger context and can lead to a discussion of the potential tradeoffs of the transfer.¹⁰ For example, the hope for a little more time from treatments available through transfer may be at odds with the hope to spend as much time as possible with family. Once the patient’s hopes are better understood, the clinician can then ask about worries. Most seriously ill patients are deeply (often silently) worried about the future, and when asked, can articulate worries about dying that can be the foundation for an honest conversation about the likely course of the hospital transfer.

With empathic assessment, several patients can speak honestly with their clinicians about their illness, including the pros and cons of hospital transfer. However, some continue to struggle, often asking clinicians to remain positive and not endorsing any worry. We describe these patients as having low prognostic awareness.¹¹ With such patients, palliative care expertise may be needed to ensure that patients and their families have the information they need to engage in informed medical decision-making. There are emerging models for distance palliative care integration, which may be helpful in these situations.¹² If these technologies became common in practice, frontline clinicians may increasingly find virtual consultation helpful in working with patients to develop more accurate prognostic awareness. There is also the possibility of clinician-to-clinician electronic consultation, or peer coaching, where the patient is not seen directly by the consultant, but expert advice is offered to the local provider.¹³ Although both these innovations offer service that currently may not be available in certain care settings, in-person consultation remains the gold standard. If a nuanced discussion cannot be had, palliative care expertise may be the reason for transfer.

Back at our hospital, I met with the patient and her partner. There were tradeoffs to be made and hard truths to be acknowledged. In this unfamiliar place, with caregivers she had met just hours before, the patient changed her resuscitation order to allow for a natural death. She passed away later that evening, surrounded by her immediate family but far away from the community that had held her throughout her illness. I reflect on the loss that can come with choosing “everything” when efforts are often better spent on ensuring comfort. Although hospital transfer is often the right answer for seriously ill patients seeking diagnostic and therapeutic options unavailable at their home medical centers, the question should also be an impetus for a nuanced assessment of patients’ prognostic awareness to prepare patients if things do not go as hoped or to enlist palliative care expertise for those struggling to cope. As there is a workforce shortage of palliative care providers, particularly in smaller and rural American hospitals, frontline hospitalist clinicians may find themselves increasingly playing a critical role in discussions where transfer is considered. By assessing patients’ prognostic awareness through thoughtful, compassionate inquiry in these moments of transition, we can support informed medical decision-making.

Opioid use disorder (OUD) is a common, underrecognized, undertreated, and deadly medical condition. Although the focus of addressing the opioid epidemic has been centered in the outpatient setting, hospitalists play an important—and often underutilized—role in identifying OUD, initiating treatment, and assisting with linkage to longitudinal care after discharge.

Over the past 20 years, the annual rate of hospital discharges documenting OUD has quadrupled.¹ During 2010-2016, the annual discharge rate for heroin overdoses increased by 23%.¹ Although the total number of hospitalizations in the United States remained stable from 2002 to 2012, the number of admissions for opioid abuse or dependence increased from 301,707 to 520,275. More than 500,000 hospital admissions per year (1% of total nationwide hospitalizations) are now due primarily to OUD.²

Injection opioid use increases the risk of endocarditis, osteomyelitis, septic arthritis, and epidural abscesses, conditions that often prolong hospitalizations and frequently lead to readmissions. Admissions for OUD-related infections are rising at a startling rate. Between 2002 and 2012, the number of admissions for infections associated with OUDs had increased from 3,421 to 6,535.² In addition to providing the opportunity to diagnose OUD, hospitalizations offer an ideal time to engage patients in OUD treatment and linkage to outpatient care.

Although we uniformly offer patients antibiotic treatment for acute infection, hospitalists should consistently incorporate treatment of OUD to address the root cause of these admissions. As infection is but one sequelae of the underlying disease of addiction, treating without medications for OUD (MOUD) would be akin to treating a diabetic foot ulcer with antibiotics and not providing medications to improve glycemic control. Omitting such addiction treatment can contribute to treatment failure and worse health outcomes. Among patients with endocarditis and an associated valve repair, those who continue injection drug use have a 10 times higher risk of death or reoperation between 90 and 180 days after repair than those not engaged in drug use.³

Despite data demonstrating the significant benefit and the minimal harm of MOUD, significant gaps remain in providing MOUD and linking patients from the hospital to community care.^1,4 Hospital encounters are missed opportunities to provide life-saving MOUD treatment; the majority of patients with OUD do not receive evidence-based treatment while inpatient.⁵ Rosenthal et al. found that of 102 patients admitted with injection drug use-associated infective endocarditis from 2004 to 2014, only 8% received MOUD, and approximately half had a documentation of substance use treatment in their discharge worksheet.⁴ In Massachusetts, among individuals who experienced a nonfatal opioid overdose and had interaction with healthcare services, only 26% were on MOUD one year later.⁶ Based on our experience, a substantial proportion of patients with OUD do not seek or have access to medical care, acute care settings offer a critical opportunity to engage them in treatment for their addiction.

First, buprenorphine effectively treats withdrawal symptoms. Buprenorphine and methadone are superior to other medications in treating symptoms of withdrawal.⁷ If withdrawal symptoms are treated, patients are less likely to leave against medical advice⁸ and are more likely to complete treatment.

Second, MOUD is the standard of care for treating OUD.⁹ Medications include the full agonist methadone, the partial agonist buprenorphine, and the long-acting antagonist naltrexone. Although all these drugs are effective and legal to initiate for inpatients,⁶ this perspective focuses on buprenorphine in an effort to draw attention to associated policy barriers. Buprenorphine is the only MOUD that can be offered as office-based therapy by providers in the outpatient setting. Meta-analyses show that MOUD is associated with lower rates of mortality, illicit opioid use, HIV transmission, and violent crime and arrest.⁹

Third, MOUD treatment, rather than just referral, leads to higher long-term treatment success.¹⁰ When initiating buprenorphine in the hospital, treatment retention rates at one month were double that of referral alone. Six months after discharge, patients were five times more likely to remain engaged in treatment compared with those who received a detoxification protocol only.

Fourth, buprenorphine is not only effective, but it is also safe and has low risks of misuse. Because buprenorphine is a partial agonist, it has both a ceiling effect on respiratory depression (decreasing potential lethality) and on euphoria (decreasing the likelihood of misuse). Among individuals who took nonprescribed buprenorphine on the street, less than 7% reported taking it for any attempt at euphoria. Instead, people with OUD most often use nonprescribed or diverted buprenorphine to treat withdrawal symptoms.¹¹

Fifth, buprenorphine treatment is associated with fewer hospital readmissions.¹²

Finally, initiating OUD treatment is feasible in the hospital setting. Any hospitalist can legally prescribe buprenorphine to treat opioid withdrawal for hospitalized patients admitted for medical or surgical reasons. A waiver is necessary only for prescribing at the time of hospital discharge for use in non-inpatient settings of care.

The United States Congress passed the Drug Addiction Treatment Act (DATA) of 2000, which codified the X waiver, in response to the growing opioid crisis. Only those providers with the DATA X waiver can write buprenorphine prescriptions to be filled in an outpatient pharmacy. To obtain an X waiver, physicians must complete an 8-hour course, whereas physician assistants and nurse practitioners must complete a 24-hour course. This training far exceeds any required training to prescribe opioids for pain.

Unfortunately, the X waiver requirement obstructs hospitalists from initiating buprenorphine in the inpatient setting in the following ways: (1) hospitalists often choose not to initiate chronic buprenorphine treatment if they lack the X waiver that would allow them to write the discharge prescription and/or (2) they are unable to identify a waivered provider in the community to continue the prescription. Unfortunately, only 6% of all medical practitioners are waivered to prescribe buprenorphine; greater than 40% of US counties are “buprenorphine deserts,” with no providers waivered to prescribe buprenorphine.¹³

To address the opioid crisis, we must rethink our current policies. The Department of Health and Human Services should eliminate the X waiver and allow any licensed physician, nurse practitioner, or physician assistant to prescribe buprenorphine.¹⁴ Recent American Medical Association Opioid Task Force recommendations have called to “remove… inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment for OUD.”¹⁵ Legislation to remove the X wavier has been proposed in the United States.¹⁶

The removal of a buprenorphine waiver requirement has had success in other settings. The French deregulation of buprenorphine was associated with a reduction in opioid overdose deaths by 79%. Similar success in the United States would save an estimated 30,000 lives yearly.¹⁴ Removing the X waiver is an important step in empowering hospitalists to initiate MOUD for individuals in the hospital setting. Moreover, it opens the door to more outpatient primary care providers serving as community linkages for long-term addiction care.

Without the X waiver, the associated OUD training will no longer be required. This could have unintended consequences. For example, if hospitalists order buprenorphine while opioids remain active, precipitated withdrawal may ensue. Crucially, the current literature does not indicate that the required X waiver training improves knowledge, patient care, or outcomes.¹⁷ Nevertheless, MOUD and addiction training may help reduce knowledge gaps and empower providers to engage in productive conversations surrounding addiction. This highlights the crucial role of physician organizations, such as the Society of Hospital Medicine, in educating hospitalists about MOUD. (This organization, among others, has developed robust MOUD training.¹⁸)

It is also important to acknowledge that the waiver is only one obstacle. Other barriers have been identified in initiating buprenorphine, including access to treatment after discharge, access to social work support, and lack of EMR order sets, among others.¹⁹ Professional societies, hospitals, and hospitalists need to help address these barriers through ancillary support staff, quality improvement initiatives, and improved inpatient treatment of withdrawal with MOUD. This can be done successfully; one study found that 82% of hospitalized patients who engaged in a new transitional opioid program subsequently presented to outpatient opioid treatment.²⁰ Novel interventions must be part of a hospital-wide approach to optimizing improved longitudinal treatment for patients suffering from addiction.

Hospitalization is an ideal opportunity for clinicians to diagnose and treat OUD in a population that often has not sought, or has fallen out of, addiction treatment. Hospitalists can and should initiate buprenorphine in appropriate inpatients and plan for their transition to chronic care. Eliminating the waiver in combination with designing innovative educational opportunities and systems approaches to provide better linkages to outpatient OUD treatment is needed to combat the opioid crisis. To enable more hospitalists to successfully initiate long-term buprenorphine therapy—and to enable more outpatient providers to continue prescriptions—we must eliminate the X waiver.

Disclosures

Dr. Wilson received honorarium from the American Society of Addiction Medicine for teaching and creating CME outside the submitted work. All other authors have no conflicts of interest and have received no related funding to this topic.

Opioid use disorder (OUD) is a common, underrecognized, undertreated, and deadly medical condition. Although the focus of addressing the opioid epidemic has been centered in the outpatient setting, hospitalists play an important—and often underutilized—role in identifying OUD, initiating treatment, and assisting with linkage to longitudinal care after discharge.

Over the past 20 years, the annual rate of hospital discharges documenting OUD has quadrupled.¹ During 2010-2016, the annual discharge rate for heroin overdoses increased by 23%.¹ Although the total number of hospitalizations in the United States remained stable from 2002 to 2012, the number of admissions for opioid abuse or dependence increased from 301,707 to 520,275. More than 500,000 hospital admissions per year (1% of total nationwide hospitalizations) are now due primarily to OUD.²

Injection opioid use increases the risk of endocarditis, osteomyelitis, septic arthritis, and epidural abscesses, conditions that often prolong hospitalizations and frequently lead to readmissions. Admissions for OUD-related infections are rising at a startling rate. Between 2002 and 2012, the number of admissions for infections associated with OUDs had increased from 3,421 to 6,535.² In addition to providing the opportunity to diagnose OUD, hospitalizations offer an ideal time to engage patients in OUD treatment and linkage to outpatient care.

Although we uniformly offer patients antibiotic treatment for acute infection, hospitalists should consistently incorporate treatment of OUD to address the root cause of these admissions. As infection is but one sequelae of the underlying disease of addiction, treating without medications for OUD (MOUD) would be akin to treating a diabetic foot ulcer with antibiotics and not providing medications to improve glycemic control. Omitting such addiction treatment can contribute to treatment failure and worse health outcomes. Among patients with endocarditis and an associated valve repair, those who continue injection drug use have a 10 times higher risk of death or reoperation between 90 and 180 days after repair than those not engaged in drug use.³

Despite data demonstrating the significant benefit and the minimal harm of MOUD, significant gaps remain in providing MOUD and linking patients from the hospital to community care.^1,4 Hospital encounters are missed opportunities to provide life-saving MOUD treatment; the majority of patients with OUD do not receive evidence-based treatment while inpatient.⁵ Rosenthal et al. found that of 102 patients admitted with injection drug use-associated infective endocarditis from 2004 to 2014, only 8% received MOUD, and approximately half had a documentation of substance use treatment in their discharge worksheet.⁴ In Massachusetts, among individuals who experienced a nonfatal opioid overdose and had interaction with healthcare services, only 26% were on MOUD one year later.⁶ Based on our experience, a substantial proportion of patients with OUD do not seek or have access to medical care, acute care settings offer a critical opportunity to engage them in treatment for their addiction.

First, buprenorphine effectively treats withdrawal symptoms. Buprenorphine and methadone are superior to other medications in treating symptoms of withdrawal.⁷ If withdrawal symptoms are treated, patients are less likely to leave against medical advice⁸ and are more likely to complete treatment.

Second, MOUD is the standard of care for treating OUD.⁹ Medications include the full agonist methadone, the partial agonist buprenorphine, and the long-acting antagonist naltrexone. Although all these drugs are effective and legal to initiate for inpatients,⁶ this perspective focuses on buprenorphine in an effort to draw attention to associated policy barriers. Buprenorphine is the only MOUD that can be offered as office-based therapy by providers in the outpatient setting. Meta-analyses show that MOUD is associated with lower rates of mortality, illicit opioid use, HIV transmission, and violent crime and arrest.⁹

Third, MOUD treatment, rather than just referral, leads to higher long-term treatment success.¹⁰ When initiating buprenorphine in the hospital, treatment retention rates at one month were double that of referral alone. Six months after discharge, patients were five times more likely to remain engaged in treatment compared with those who received a detoxification protocol only.

Fourth, buprenorphine is not only effective, but it is also safe and has low risks of misuse. Because buprenorphine is a partial agonist, it has both a ceiling effect on respiratory depression (decreasing potential lethality) and on euphoria (decreasing the likelihood of misuse). Among individuals who took nonprescribed buprenorphine on the street, less than 7% reported taking it for any attempt at euphoria. Instead, people with OUD most often use nonprescribed or diverted buprenorphine to treat withdrawal symptoms.¹¹

Fifth, buprenorphine treatment is associated with fewer hospital readmissions.¹²

Finally, initiating OUD treatment is feasible in the hospital setting. Any hospitalist can legally prescribe buprenorphine to treat opioid withdrawal for hospitalized patients admitted for medical or surgical reasons. A waiver is necessary only for prescribing at the time of hospital discharge for use in non-inpatient settings of care.

The United States Congress passed the Drug Addiction Treatment Act (DATA) of 2000, which codified the X waiver, in response to the growing opioid crisis. Only those providers with the DATA X waiver can write buprenorphine prescriptions to be filled in an outpatient pharmacy. To obtain an X waiver, physicians must complete an 8-hour course, whereas physician assistants and nurse practitioners must complete a 24-hour course. This training far exceeds any required training to prescribe opioids for pain.

Unfortunately, the X waiver requirement obstructs hospitalists from initiating buprenorphine in the inpatient setting in the following ways: (1) hospitalists often choose not to initiate chronic buprenorphine treatment if they lack the X waiver that would allow them to write the discharge prescription and/or (2) they are unable to identify a waivered provider in the community to continue the prescription. Unfortunately, only 6% of all medical practitioners are waivered to prescribe buprenorphine; greater than 40% of US counties are “buprenorphine deserts,” with no providers waivered to prescribe buprenorphine.¹³

To address the opioid crisis, we must rethink our current policies. The Department of Health and Human Services should eliminate the X waiver and allow any licensed physician, nurse practitioner, or physician assistant to prescribe buprenorphine.¹⁴ Recent American Medical Association Opioid Task Force recommendations have called to “remove… inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment for OUD.”¹⁵ Legislation to remove the X wavier has been proposed in the United States.¹⁶

The removal of a buprenorphine waiver requirement has had success in other settings. The French deregulation of buprenorphine was associated with a reduction in opioid overdose deaths by 79%. Similar success in the United States would save an estimated 30,000 lives yearly.¹⁴ Removing the X waiver is an important step in empowering hospitalists to initiate MOUD for individuals in the hospital setting. Moreover, it opens the door to more outpatient primary care providers serving as community linkages for long-term addiction care.

Without the X waiver, the associated OUD training will no longer be required. This could have unintended consequences. For example, if hospitalists order buprenorphine while opioids remain active, precipitated withdrawal may ensue. Crucially, the current literature does not indicate that the required X waiver training improves knowledge, patient care, or outcomes.¹⁷ Nevertheless, MOUD and addiction training may help reduce knowledge gaps and empower providers to engage in productive conversations surrounding addiction. This highlights the crucial role of physician organizations, such as the Society of Hospital Medicine, in educating hospitalists about MOUD. (This organization, among others, has developed robust MOUD training.¹⁸)

It is also important to acknowledge that the waiver is only one obstacle. Other barriers have been identified in initiating buprenorphine, including access to treatment after discharge, access to social work support, and lack of EMR order sets, among others.¹⁹ Professional societies, hospitals, and hospitalists need to help address these barriers through ancillary support staff, quality improvement initiatives, and improved inpatient treatment of withdrawal with MOUD. This can be done successfully; one study found that 82% of hospitalized patients who engaged in a new transitional opioid program subsequently presented to outpatient opioid treatment.²⁰ Novel interventions must be part of a hospital-wide approach to optimizing improved longitudinal treatment for patients suffering from addiction.

Hospitalization is an ideal opportunity for clinicians to diagnose and treat OUD in a population that often has not sought, or has fallen out of, addiction treatment. Hospitalists can and should initiate buprenorphine in appropriate inpatients and plan for their transition to chronic care. Eliminating the waiver in combination with designing innovative educational opportunities and systems approaches to provide better linkages to outpatient OUD treatment is needed to combat the opioid crisis. To enable more hospitalists to successfully initiate long-term buprenorphine therapy—and to enable more outpatient providers to continue prescriptions—we must eliminate the X waiver.

Disclosures

Dr. Wilson received honorarium from the American Society of Addiction Medicine for teaching and creating CME outside the submitted work. All other authors have no conflicts of interest and have received no related funding to this topic.

Opioid use disorder (OUD) is a common, underrecognized, undertreated, and deadly medical condition. Although the focus of addressing the opioid epidemic has been centered in the outpatient setting, hospitalists play an important—and often underutilized—role in identifying OUD, initiating treatment, and assisting with linkage to longitudinal care after discharge.

Over the past 20 years, the annual rate of hospital discharges documenting OUD has quadrupled.¹ During 2010-2016, the annual discharge rate for heroin overdoses increased by 23%.¹ Although the total number of hospitalizations in the United States remained stable from 2002 to 2012, the number of admissions for opioid abuse or dependence increased from 301,707 to 520,275. More than 500,000 hospital admissions per year (1% of total nationwide hospitalizations) are now due primarily to OUD.²

Injection opioid use increases the risk of endocarditis, osteomyelitis, septic arthritis, and epidural abscesses, conditions that often prolong hospitalizations and frequently lead to readmissions. Admissions for OUD-related infections are rising at a startling rate. Between 2002 and 2012, the number of admissions for infections associated with OUDs had increased from 3,421 to 6,535.² In addition to providing the opportunity to diagnose OUD, hospitalizations offer an ideal time to engage patients in OUD treatment and linkage to outpatient care.

Although we uniformly offer patients antibiotic treatment for acute infection, hospitalists should consistently incorporate treatment of OUD to address the root cause of these admissions. As infection is but one sequelae of the underlying disease of addiction, treating without medications for OUD (MOUD) would be akin to treating a diabetic foot ulcer with antibiotics and not providing medications to improve glycemic control. Omitting such addiction treatment can contribute to treatment failure and worse health outcomes. Among patients with endocarditis and an associated valve repair, those who continue injection drug use have a 10 times higher risk of death or reoperation between 90 and 180 days after repair than those not engaged in drug use.³

Despite data demonstrating the significant benefit and the minimal harm of MOUD, significant gaps remain in providing MOUD and linking patients from the hospital to community care.^1,4 Hospital encounters are missed opportunities to provide life-saving MOUD treatment; the majority of patients with OUD do not receive evidence-based treatment while inpatient.⁵ Rosenthal et al. found that of 102 patients admitted with injection drug use-associated infective endocarditis from 2004 to 2014, only 8% received MOUD, and approximately half had a documentation of substance use treatment in their discharge worksheet.⁴ In Massachusetts, among individuals who experienced a nonfatal opioid overdose and had interaction with healthcare services, only 26% were on MOUD one year later.⁶ Based on our experience, a substantial proportion of patients with OUD do not seek or have access to medical care, acute care settings offer a critical opportunity to engage them in treatment for their addiction.

First, buprenorphine effectively treats withdrawal symptoms. Buprenorphine and methadone are superior to other medications in treating symptoms of withdrawal.⁷ If withdrawal symptoms are treated, patients are less likely to leave against medical advice⁸ and are more likely to complete treatment.

Second, MOUD is the standard of care for treating OUD.⁹ Medications include the full agonist methadone, the partial agonist buprenorphine, and the long-acting antagonist naltrexone. Although all these drugs are effective and legal to initiate for inpatients,⁶ this perspective focuses on buprenorphine in an effort to draw attention to associated policy barriers. Buprenorphine is the only MOUD that can be offered as office-based therapy by providers in the outpatient setting. Meta-analyses show that MOUD is associated with lower rates of mortality, illicit opioid use, HIV transmission, and violent crime and arrest.⁹

Third, MOUD treatment, rather than just referral, leads to higher long-term treatment success.¹⁰ When initiating buprenorphine in the hospital, treatment retention rates at one month were double that of referral alone. Six months after discharge, patients were five times more likely to remain engaged in treatment compared with those who received a detoxification protocol only.

Fourth, buprenorphine is not only effective, but it is also safe and has low risks of misuse. Because buprenorphine is a partial agonist, it has both a ceiling effect on respiratory depression (decreasing potential lethality) and on euphoria (decreasing the likelihood of misuse). Among individuals who took nonprescribed buprenorphine on the street, less than 7% reported taking it for any attempt at euphoria. Instead, people with OUD most often use nonprescribed or diverted buprenorphine to treat withdrawal symptoms.¹¹

Fifth, buprenorphine treatment is associated with fewer hospital readmissions.¹²

Finally, initiating OUD treatment is feasible in the hospital setting. Any hospitalist can legally prescribe buprenorphine to treat opioid withdrawal for hospitalized patients admitted for medical or surgical reasons. A waiver is necessary only for prescribing at the time of hospital discharge for use in non-inpatient settings of care.

The United States Congress passed the Drug Addiction Treatment Act (DATA) of 2000, which codified the X waiver, in response to the growing opioid crisis. Only those providers with the DATA X waiver can write buprenorphine prescriptions to be filled in an outpatient pharmacy. To obtain an X waiver, physicians must complete an 8-hour course, whereas physician assistants and nurse practitioners must complete a 24-hour course. This training far exceeds any required training to prescribe opioids for pain.

Unfortunately, the X waiver requirement obstructs hospitalists from initiating buprenorphine in the inpatient setting in the following ways: (1) hospitalists often choose not to initiate chronic buprenorphine treatment if they lack the X waiver that would allow them to write the discharge prescription and/or (2) they are unable to identify a waivered provider in the community to continue the prescription. Unfortunately, only 6% of all medical practitioners are waivered to prescribe buprenorphine; greater than 40% of US counties are “buprenorphine deserts,” with no providers waivered to prescribe buprenorphine.¹³

To address the opioid crisis, we must rethink our current policies. The Department of Health and Human Services should eliminate the X waiver and allow any licensed physician, nurse practitioner, or physician assistant to prescribe buprenorphine.¹⁴ Recent American Medical Association Opioid Task Force recommendations have called to “remove… inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment for OUD.”¹⁵ Legislation to remove the X wavier has been proposed in the United States.¹⁶

The removal of a buprenorphine waiver requirement has had success in other settings. The French deregulation of buprenorphine was associated with a reduction in opioid overdose deaths by 79%. Similar success in the United States would save an estimated 30,000 lives yearly.¹⁴ Removing the X waiver is an important step in empowering hospitalists to initiate MOUD for individuals in the hospital setting. Moreover, it opens the door to more outpatient primary care providers serving as community linkages for long-term addiction care.

Without the X waiver, the associated OUD training will no longer be required. This could have unintended consequences. For example, if hospitalists order buprenorphine while opioids remain active, precipitated withdrawal may ensue. Crucially, the current literature does not indicate that the required X waiver training improves knowledge, patient care, or outcomes.¹⁷ Nevertheless, MOUD and addiction training may help reduce knowledge gaps and empower providers to engage in productive conversations surrounding addiction. This highlights the crucial role of physician organizations, such as the Society of Hospital Medicine, in educating hospitalists about MOUD. (This organization, among others, has developed robust MOUD training.¹⁸)

It is also important to acknowledge that the waiver is only one obstacle. Other barriers have been identified in initiating buprenorphine, including access to treatment after discharge, access to social work support, and lack of EMR order sets, among others.¹⁹ Professional societies, hospitals, and hospitalists need to help address these barriers through ancillary support staff, quality improvement initiatives, and improved inpatient treatment of withdrawal with MOUD. This can be done successfully; one study found that 82% of hospitalized patients who engaged in a new transitional opioid program subsequently presented to outpatient opioid treatment.²⁰ Novel interventions must be part of a hospital-wide approach to optimizing improved longitudinal treatment for patients suffering from addiction.

Hospitalization is an ideal opportunity for clinicians to diagnose and treat OUD in a population that often has not sought, or has fallen out of, addiction treatment. Hospitalists can and should initiate buprenorphine in appropriate inpatients and plan for their transition to chronic care. Eliminating the waiver in combination with designing innovative educational opportunities and systems approaches to provide better linkages to outpatient OUD treatment is needed to combat the opioid crisis. To enable more hospitalists to successfully initiate long-term buprenorphine therapy—and to enable more outpatient providers to continue prescriptions—we must eliminate the X waiver.

Disclosures

Dr. Wilson received honorarium from the American Society of Addiction Medicine for teaching and creating CME outside the submitted work. All other authors have no conflicts of interest and have received no related funding to this topic.

Hilda and I shared childhood stories while we enjoyed one of her favorite Mexican dishes, grilled nopalitos (cactus). Hilda loved nopalitos, but she rarely ate them because they are high in potassium. Hilda had end-stage kidney disease (ESKD), and as an undocumented Mexican immigrant in Denver, CO, she relied on emergency-only hemodialysis. Instead of receiving standard hemodialysis three times per week as required, Hilda would arrive critically ill to the hospital after her nausea, vomiting, and shortness of breath became unbearable. After three cardiac arrests from high potassium levels, she fervently avoided foods high in it. This time, however, she was not worried about potassium. This was our last meal together. She would fly to Mexico a few days later to die.

Our hospital medicine team knew Hilda well. We had continuity because we had been admitting her to the intensive care unit or medicine floor one night each week to receive two hemodialysis sessions when she was critically ill. I immediately connected with Hilda because our lives were parallel in many ways. Hilda and I were both in our early 30s, English was our second language, we both grew up in poverty, and we now had children in elementary school. I, however, was documented. My United States citizenship allowed me the privilege of pursuing a medical degree and gaining access to quality healthcare. In contrast, Hilda had been forced to end her education prematurely, marry her mother’s friend for financial stability at the age of 14, and eventually flee to the US to escape poverty. She survived by cleaning homes until her kidneys failed. Initially, Hilda was my patient. Over time, she became a dear friend.

The first two years of emergency-only hemodialysis devastated Hilda. Too sick to work, she became homeless, staying with a nurse until we found a shelter for single mothers. Multiple cardiac arrests and resuscitations traumatized her young sons, who called 911 each time she collapsed and witnessed the resuscitations. Her boys did not understand the cycle of separation from their mother for her emergent, weekly dialysis hospital admissions and wondered if she would survive to the following week. After two years of emergency-only dialysis, Hilda’s deep love for her boys and concern about the possibility that her sudden death could leave them alone led her to pre-emptively decide to stop emergency-only dialysis. Had Hilda’s treatment costs been covered by emergency Medicaid, as undocumented immigrants with ESKD are in some other states, she may not have been forced into this terrible decision. Moving to a state where standard dialysis is covered was not an option for Hilda because she wanted her boys to stay in Colorado where they had family and friends. With no other options, she first sought a loving adoptive family in the US so that her boys could grow up and have the opportunity to pursue an education. After carefully finding the right adoptive parents, Hilda wanted to celebrate her life with the people she loved. To show her gratitude, she organized a large Mexican Christmas party and invited all of the healthcare providers and friends that had supported her. She generously gave everyone a small gift to remember her by from the few things she owned. I received the wooden rosary her father had left her. A short while later, Hilda flew home to Mexico and passed away on Mother’s Day in 2014.

Two years of caring for Hilda as an internal medicine hospitalist changed me. Grief gave way to anger, anger to determination. I found it morally distressing to continue to provide this type of care. Something had to change and there was little research in this area. One small study had demonstrated that emergency-only hemodialysis was nearly four-fold more expensive due to additional visits to the emergency department and admissions to the hospital, compared to standard outpatient hemodialysis.¹ After much soul-searching and advice seeking, I scaled down my clinical hospitalist shifts and gathered a team to do research. For four years, we worked on illuminating the suffering of undocumented immigrants with ESKD that rely on emergency-only hemodialysis. We conducted 20 individual face-to-face qualitative interviews with undocumented immigrants with ESKD and heard first-hand about the emotional and physical burdens and the existential anxiety associated with weekly threats to life.² We published a retrospective cohort study looking at differences in mortality and found that immigrants who relied on emergency-only hemodialysis had a 14-fold greater mortality rate than those on standard hemodialysis five years after initiating hemodialysis.³ In another retrospective study, we described the circumstances among undocumented immigrants with ESKD who died in the hospital after presenting with ESKD complications, and found that the majority presented with high potassium and a recorded rhythm disturbance.⁴ I discovered that as a hospitalist physician, I was not the only one distressed. We conducted 50 qualitative interviews to determine the perspectives of interdisciplinary clinicians on providing emergency dialysis and found that there are more clinicians experiencing moral distress. They described several important drivers of burnout,⁵ including emotional exhaustion from witnessing needless suffering and high mortality, as well as physical exhaustion from overextending themselves to bridge their patient’s care. Together, we discovered that the research told the larger narrative behind Hilda’s struggles. These publications caught the attention of the media and enabled us to speak to a wider audience of clinicians, health policy makers, and the general public.^6-10 They also became a catalyst to engaging and enlisting the good will and interest of a number of key stakeholders to look for solutions.

In the US, undocumented immigrants do not qualify for insurance through traditional Medicaid, Medicare, or the provisions from the Patient Protection and Affordable Care Act. Instead, emergency Medicaid provides reimbursements for care of undocumented immigrants. According to the 1986 Emergency Medicaid Treatment and Active Labor Act, federal Medicaid payments can only be made for the care of undocumented immigrants if care is necessary for the treatment of an emergency medical condition.¹¹ However, the Centers for Medicare and Medicaid (CMS) has outlined certain conditions that cannot qualify for matching federal funds under emergency Medicaid (ie, organ transplant and routine prenatal or postpartum care). Beyond these requirements, federal CMS and the Office of the Inspector General defer to states to define what constitutes a medical emergency. A few states include ESKD in the definition of “emergency medical condition,” thereby expanding access to standard hemodialysis to undocumented immigrants. We wanted Colorado to join that list.

On August 2018, after four years of research and months of dialog, everything changed: Colorado Medicaid announced that ESKD was now an “emergency medical condition.” As simple as that, undocumented immigrants would receive standard maintenance hemodialysis. Tears streamed down my face as I read a message from a policy specialist from the Colorado Medicaid: Your team “played a big role in bringing awareness to this issue, and your advocacy for these patients is impressive … thank you for fighting for such an important cause.” I reread her message, imagining what this would have meant to Hilda and her boys.

Our work to enhance care in this community is not over. To better understand the provision of dialysis care for undocumented immigrants in the United States, our team reviewed the Medicaid language for each of the 50 US states in addition to connecting with clinicians and organizations (eg, National Kidney Foundation and ESKD Networks). We found that only 12 states provide Medicaid reimbursement for standard dialysis and that a majority of the US states do not currently define need for dialysis as an emergency medical condition.¹² As our Colorado team works with stakeholders in other states interested in similarly redefining their state’s emergency Medicaid definition, our most important advice is that advocacy is a team-based effort. There may be resistance and some may argue that expanding access to care would be an economic burden on taxpayers; however, research demonstrates that undocumented immigrants contribute more to the US Medicare Trust Fund than they actually withdraw toward healthcare.¹³ Furthermore, a new study has demonstrated that a net savings of nearly $6,000 per person per month is realized when patients are transitioned from emergency-only hemodialysis to standard hemodialysis.¹⁴

Internal medicine hospitalists on the front-line of healthcare systems are regular witnesses to its horrible injustices. We rarely share our perspectives and do not expect change to follow. With Hilda, we saw how a powerful combination of research and coalition building could lift one patient’s tragic story to a level where it could produce change. Augmenting Hilda’s experience of tragically poor access to care with evidence-based research gave her story validity far beyond our immediate circle of friends and colleagues, making a singular tragedy, policy relevant. Each time we shared our research to community advocacy groups, health policy stakeholders, state legislators, nurses, and staff; we began with Hilda’s story, not just because it inspired us, but because its truth was undeniable. Our patients’ stories matter, and it is our responsibility to tell them.

Each time I prepare nopalitos for my family, I think of my last meal with Hilda. No matter how painful or difficult her struggle with ESKD, Hilda persisted. She protected her boys. They were her purpose. When she knew she could no longer give them the life she wanted for them, she found a family who would. Hilda’s sons now live with a loving adoptive family, are thriving in school, and her oldest is interested in becoming a physician. Nopal, or cactus, symbolizes such endurance—a plant with unique adaptations and strength that can flourish under extreme environmental stress. Like a cactus storing precious water, Hilda treasured her children, and her resolve to provide for them was unstoppable, right to the edge of death. When our team first took up Hilda’s cause, change seemed impossible. We discovered the opposite. As I clench the wooden rosary she left me that Christmas, I thank her for giving our team the courage to adapt and persist, for in doing so we found a path, first to research and then to broader partnerships and more meaningful policy changes.

Acknowledgments

The author would like to thank Hilda, her family, and the patients at Denver Health. She would also like to acknowledge Hilda’s family, Drs. Mark Earnest, John F. Steiner, Romana Hasnain-Wynia, Rudolph Rodriguez, Judy Regensteiner, and Michel Chonchol for reading and providing feedback on earlier drafts of this narrative.

Hilda and I shared childhood stories while we enjoyed one of her favorite Mexican dishes, grilled nopalitos (cactus). Hilda loved nopalitos, but she rarely ate them because they are high in potassium. Hilda had end-stage kidney disease (ESKD), and as an undocumented Mexican immigrant in Denver, CO, she relied on emergency-only hemodialysis. Instead of receiving standard hemodialysis three times per week as required, Hilda would arrive critically ill to the hospital after her nausea, vomiting, and shortness of breath became unbearable. After three cardiac arrests from high potassium levels, she fervently avoided foods high in it. This time, however, she was not worried about potassium. This was our last meal together. She would fly to Mexico a few days later to die.

Our hospital medicine team knew Hilda well. We had continuity because we had been admitting her to the intensive care unit or medicine floor one night each week to receive two hemodialysis sessions when she was critically ill. I immediately connected with Hilda because our lives were parallel in many ways. Hilda and I were both in our early 30s, English was our second language, we both grew up in poverty, and we now had children in elementary school. I, however, was documented. My United States citizenship allowed me the privilege of pursuing a medical degree and gaining access to quality healthcare. In contrast, Hilda had been forced to end her education prematurely, marry her mother’s friend for financial stability at the age of 14, and eventually flee to the US to escape poverty. She survived by cleaning homes until her kidneys failed. Initially, Hilda was my patient. Over time, she became a dear friend.

The first two years of emergency-only hemodialysis devastated Hilda. Too sick to work, she became homeless, staying with a nurse until we found a shelter for single mothers. Multiple cardiac arrests and resuscitations traumatized her young sons, who called 911 each time she collapsed and witnessed the resuscitations. Her boys did not understand the cycle of separation from their mother for her emergent, weekly dialysis hospital admissions and wondered if she would survive to the following week. After two years of emergency-only dialysis, Hilda’s deep love for her boys and concern about the possibility that her sudden death could leave them alone led her to pre-emptively decide to stop emergency-only dialysis. Had Hilda’s treatment costs been covered by emergency Medicaid, as undocumented immigrants with ESKD are in some other states, she may not have been forced into this terrible decision. Moving to a state where standard dialysis is covered was not an option for Hilda because she wanted her boys to stay in Colorado where they had family and friends. With no other options, she first sought a loving adoptive family in the US so that her boys could grow up and have the opportunity to pursue an education. After carefully finding the right adoptive parents, Hilda wanted to celebrate her life with the people she loved. To show her gratitude, she organized a large Mexican Christmas party and invited all of the healthcare providers and friends that had supported her. She generously gave everyone a small gift to remember her by from the few things she owned. I received the wooden rosary her father had left her. A short while later, Hilda flew home to Mexico and passed away on Mother’s Day in 2014.

Two years of caring for Hilda as an internal medicine hospitalist changed me. Grief gave way to anger, anger to determination. I found it morally distressing to continue to provide this type of care. Something had to change and there was little research in this area. One small study had demonstrated that emergency-only hemodialysis was nearly four-fold more expensive due to additional visits to the emergency department and admissions to the hospital, compared to standard outpatient hemodialysis.¹ After much soul-searching and advice seeking, I scaled down my clinical hospitalist shifts and gathered a team to do research. For four years, we worked on illuminating the suffering of undocumented immigrants with ESKD that rely on emergency-only hemodialysis. We conducted 20 individual face-to-face qualitative interviews with undocumented immigrants with ESKD and heard first-hand about the emotional and physical burdens and the existential anxiety associated with weekly threats to life.² We published a retrospective cohort study looking at differences in mortality and found that immigrants who relied on emergency-only hemodialysis had a 14-fold greater mortality rate than those on standard hemodialysis five years after initiating hemodialysis.³ In another retrospective study, we described the circumstances among undocumented immigrants with ESKD who died in the hospital after presenting with ESKD complications, and found that the majority presented with high potassium and a recorded rhythm disturbance.⁴ I discovered that as a hospitalist physician, I was not the only one distressed. We conducted 50 qualitative interviews to determine the perspectives of interdisciplinary clinicians on providing emergency dialysis and found that there are more clinicians experiencing moral distress. They described several important drivers of burnout,⁵ including emotional exhaustion from witnessing needless suffering and high mortality, as well as physical exhaustion from overextending themselves to bridge their patient’s care. Together, we discovered that the research told the larger narrative behind Hilda’s struggles. These publications caught the attention of the media and enabled us to speak to a wider audience of clinicians, health policy makers, and the general public.^6-10 They also became a catalyst to engaging and enlisting the good will and interest of a number of key stakeholders to look for solutions.

In the US, undocumented immigrants do not qualify for insurance through traditional Medicaid, Medicare, or the provisions from the Patient Protection and Affordable Care Act. Instead, emergency Medicaid provides reimbursements for care of undocumented immigrants. According to the 1986 Emergency Medicaid Treatment and Active Labor Act, federal Medicaid payments can only be made for the care of undocumented immigrants if care is necessary for the treatment of an emergency medical condition.¹¹ However, the Centers for Medicare and Medicaid (CMS) has outlined certain conditions that cannot qualify for matching federal funds under emergency Medicaid (ie, organ transplant and routine prenatal or postpartum care). Beyond these requirements, federal CMS and the Office of the Inspector General defer to states to define what constitutes a medical emergency. A few states include ESKD in the definition of “emergency medical condition,” thereby expanding access to standard hemodialysis to undocumented immigrants. We wanted Colorado to join that list.

On August 2018, after four years of research and months of dialog, everything changed: Colorado Medicaid announced that ESKD was now an “emergency medical condition.” As simple as that, undocumented immigrants would receive standard maintenance hemodialysis. Tears streamed down my face as I read a message from a policy specialist from the Colorado Medicaid: Your team “played a big role in bringing awareness to this issue, and your advocacy for these patients is impressive … thank you for fighting for such an important cause.” I reread her message, imagining what this would have meant to Hilda and her boys.

Our work to enhance care in this community is not over. To better understand the provision of dialysis care for undocumented immigrants in the United States, our team reviewed the Medicaid language for each of the 50 US states in addition to connecting with clinicians and organizations (eg, National Kidney Foundation and ESKD Networks). We found that only 12 states provide Medicaid reimbursement for standard dialysis and that a majority of the US states do not currently define need for dialysis as an emergency medical condition.¹² As our Colorado team works with stakeholders in other states interested in similarly redefining their state’s emergency Medicaid definition, our most important advice is that advocacy is a team-based effort. There may be resistance and some may argue that expanding access to care would be an economic burden on taxpayers; however, research demonstrates that undocumented immigrants contribute more to the US Medicare Trust Fund than they actually withdraw toward healthcare.¹³ Furthermore, a new study has demonstrated that a net savings of nearly $6,000 per person per month is realized when patients are transitioned from emergency-only hemodialysis to standard hemodialysis.¹⁴

Internal medicine hospitalists on the front-line of healthcare systems are regular witnesses to its horrible injustices. We rarely share our perspectives and do not expect change to follow. With Hilda, we saw how a powerful combination of research and coalition building could lift one patient’s tragic story to a level where it could produce change. Augmenting Hilda’s experience of tragically poor access to care with evidence-based research gave her story validity far beyond our immediate circle of friends and colleagues, making a singular tragedy, policy relevant. Each time we shared our research to community advocacy groups, health policy stakeholders, state legislators, nurses, and staff; we began with Hilda’s story, not just because it inspired us, but because its truth was undeniable. Our patients’ stories matter, and it is our responsibility to tell them.

Each time I prepare nopalitos for my family, I think of my last meal with Hilda. No matter how painful or difficult her struggle with ESKD, Hilda persisted. She protected her boys. They were her purpose. When she knew she could no longer give them the life she wanted for them, she found a family who would. Hilda’s sons now live with a loving adoptive family, are thriving in school, and her oldest is interested in becoming a physician. Nopal, or cactus, symbolizes such endurance—a plant with unique adaptations and strength that can flourish under extreme environmental stress. Like a cactus storing precious water, Hilda treasured her children, and her resolve to provide for them was unstoppable, right to the edge of death. When our team first took up Hilda’s cause, change seemed impossible. We discovered the opposite. As I clench the wooden rosary she left me that Christmas, I thank her for giving our team the courage to adapt and persist, for in doing so we found a path, first to research and then to broader partnerships and more meaningful policy changes.

Acknowledgments

The author would like to thank Hilda, her family, and the patients at Denver Health. She would also like to acknowledge Hilda’s family, Drs. Mark Earnest, John F. Steiner, Romana Hasnain-Wynia, Rudolph Rodriguez, Judy Regensteiner, and Michel Chonchol for reading and providing feedback on earlier drafts of this narrative.

Hilda and I shared childhood stories while we enjoyed one of her favorite Mexican dishes, grilled nopalitos (cactus). Hilda loved nopalitos, but she rarely ate them because they are high in potassium. Hilda had end-stage kidney disease (ESKD), and as an undocumented Mexican immigrant in Denver, CO, she relied on emergency-only hemodialysis. Instead of receiving standard hemodialysis three times per week as required, Hilda would arrive critically ill to the hospital after her nausea, vomiting, and shortness of breath became unbearable. After three cardiac arrests from high potassium levels, she fervently avoided foods high in it. This time, however, she was not worried about potassium. This was our last meal together. She would fly to Mexico a few days later to die.

Our hospital medicine team knew Hilda well. We had continuity because we had been admitting her to the intensive care unit or medicine floor one night each week to receive two hemodialysis sessions when she was critically ill. I immediately connected with Hilda because our lives were parallel in many ways. Hilda and I were both in our early 30s, English was our second language, we both grew up in poverty, and we now had children in elementary school. I, however, was documented. My United States citizenship allowed me the privilege of pursuing a medical degree and gaining access to quality healthcare. In contrast, Hilda had been forced to end her education prematurely, marry her mother’s friend for financial stability at the age of 14, and eventually flee to the US to escape poverty. She survived by cleaning homes until her kidneys failed. Initially, Hilda was my patient. Over time, she became a dear friend.

The first two years of emergency-only hemodialysis devastated Hilda. Too sick to work, she became homeless, staying with a nurse until we found a shelter for single mothers. Multiple cardiac arrests and resuscitations traumatized her young sons, who called 911 each time she collapsed and witnessed the resuscitations. Her boys did not understand the cycle of separation from their mother for her emergent, weekly dialysis hospital admissions and wondered if she would survive to the following week. After two years of emergency-only dialysis, Hilda’s deep love for her boys and concern about the possibility that her sudden death could leave them alone led her to pre-emptively decide to stop emergency-only dialysis. Had Hilda’s treatment costs been covered by emergency Medicaid, as undocumented immigrants with ESKD are in some other states, she may not have been forced into this terrible decision. Moving to a state where standard dialysis is covered was not an option for Hilda because she wanted her boys to stay in Colorado where they had family and friends. With no other options, she first sought a loving adoptive family in the US so that her boys could grow up and have the opportunity to pursue an education. After carefully finding the right adoptive parents, Hilda wanted to celebrate her life with the people she loved. To show her gratitude, she organized a large Mexican Christmas party and invited all of the healthcare providers and friends that had supported her. She generously gave everyone a small gift to remember her by from the few things she owned. I received the wooden rosary her father had left her. A short while later, Hilda flew home to Mexico and passed away on Mother’s Day in 2014.

Two years of caring for Hilda as an internal medicine hospitalist changed me. Grief gave way to anger, anger to determination. I found it morally distressing to continue to provide this type of care. Something had to change and there was little research in this area. One small study had demonstrated that emergency-only hemodialysis was nearly four-fold more expensive due to additional visits to the emergency department and admissions to the hospital, compared to standard outpatient hemodialysis.¹ After much soul-searching and advice seeking, I scaled down my clinical hospitalist shifts and gathered a team to do research. For four years, we worked on illuminating the suffering of undocumented immigrants with ESKD that rely on emergency-only hemodialysis. We conducted 20 individual face-to-face qualitative interviews with undocumented immigrants with ESKD and heard first-hand about the emotional and physical burdens and the existential anxiety associated with weekly threats to life.² We published a retrospective cohort study looking at differences in mortality and found that immigrants who relied on emergency-only hemodialysis had a 14-fold greater mortality rate than those on standard hemodialysis five years after initiating hemodialysis.³ In another retrospective study, we described the circumstances among undocumented immigrants with ESKD who died in the hospital after presenting with ESKD complications, and found that the majority presented with high potassium and a recorded rhythm disturbance.⁴ I discovered that as a hospitalist physician, I was not the only one distressed. We conducted 50 qualitative interviews to determine the perspectives of interdisciplinary clinicians on providing emergency dialysis and found that there are more clinicians experiencing moral distress. They described several important drivers of burnout,⁵ including emotional exhaustion from witnessing needless suffering and high mortality, as well as physical exhaustion from overextending themselves to bridge their patient’s care. Together, we discovered that the research told the larger narrative behind Hilda’s struggles. These publications caught the attention of the media and enabled us to speak to a wider audience of clinicians, health policy makers, and the general public.^6-10 They also became a catalyst to engaging and enlisting the good will and interest of a number of key stakeholders to look for solutions.

In the US, undocumented immigrants do not qualify for insurance through traditional Medicaid, Medicare, or the provisions from the Patient Protection and Affordable Care Act. Instead, emergency Medicaid provides reimbursements for care of undocumented immigrants. According to the 1986 Emergency Medicaid Treatment and Active Labor Act, federal Medicaid payments can only be made for the care of undocumented immigrants if care is necessary for the treatment of an emergency medical condition.¹¹ However, the Centers for Medicare and Medicaid (CMS) has outlined certain conditions that cannot qualify for matching federal funds under emergency Medicaid (ie, organ transplant and routine prenatal or postpartum care). Beyond these requirements, federal CMS and the Office of the Inspector General defer to states to define what constitutes a medical emergency. A few states include ESKD in the definition of “emergency medical condition,” thereby expanding access to standard hemodialysis to undocumented immigrants. We wanted Colorado to join that list.

On August 2018, after four years of research and months of dialog, everything changed: Colorado Medicaid announced that ESKD was now an “emergency medical condition.” As simple as that, undocumented immigrants would receive standard maintenance hemodialysis. Tears streamed down my face as I read a message from a policy specialist from the Colorado Medicaid: Your team “played a big role in bringing awareness to this issue, and your advocacy for these patients is impressive … thank you for fighting for such an important cause.” I reread her message, imagining what this would have meant to Hilda and her boys.

Our work to enhance care in this community is not over. To better understand the provision of dialysis care for undocumented immigrants in the United States, our team reviewed the Medicaid language for each of the 50 US states in addition to connecting with clinicians and organizations (eg, National Kidney Foundation and ESKD Networks). We found that only 12 states provide Medicaid reimbursement for standard dialysis and that a majority of the US states do not currently define need for dialysis as an emergency medical condition.¹² As our Colorado team works with stakeholders in other states interested in similarly redefining their state’s emergency Medicaid definition, our most important advice is that advocacy is a team-based effort. There may be resistance and some may argue that expanding access to care would be an economic burden on taxpayers; however, research demonstrates that undocumented immigrants contribute more to the US Medicare Trust Fund than they actually withdraw toward healthcare.¹³ Furthermore, a new study has demonstrated that a net savings of nearly $6,000 per person per month is realized when patients are transitioned from emergency-only hemodialysis to standard hemodialysis.¹⁴

Internal medicine hospitalists on the front-line of healthcare systems are regular witnesses to its horrible injustices. We rarely share our perspectives and do not expect change to follow. With Hilda, we saw how a powerful combination of research and coalition building could lift one patient’s tragic story to a level where it could produce change. Augmenting Hilda’s experience of tragically poor access to care with evidence-based research gave her story validity far beyond our immediate circle of friends and colleagues, making a singular tragedy, policy relevant. Each time we shared our research to community advocacy groups, health policy stakeholders, state legislators, nurses, and staff; we began with Hilda’s story, not just because it inspired us, but because its truth was undeniable. Our patients’ stories matter, and it is our responsibility to tell them.

Each time I prepare nopalitos for my family, I think of my last meal with Hilda. No matter how painful or difficult her struggle with ESKD, Hilda persisted. She protected her boys. They were her purpose. When she knew she could no longer give them the life she wanted for them, she found a family who would. Hilda’s sons now live with a loving adoptive family, are thriving in school, and her oldest is interested in becoming a physician. Nopal, or cactus, symbolizes such endurance—a plant with unique adaptations and strength that can flourish under extreme environmental stress. Like a cactus storing precious water, Hilda treasured her children, and her resolve to provide for them was unstoppable, right to the edge of death. When our team first took up Hilda’s cause, change seemed impossible. We discovered the opposite. As I clench the wooden rosary she left me that Christmas, I thank her for giving our team the courage to adapt and persist, for in doing so we found a path, first to research and then to broader partnerships and more meaningful policy changes.

Acknowledgments

The author would like to thank Hilda, her family, and the patients at Denver Health. She would also like to acknowledge Hilda’s family, Drs. Mark Earnest, John F. Steiner, Romana Hasnain-Wynia, Rudolph Rodriguez, Judy Regensteiner, and Michel Chonchol for reading and providing feedback on earlier drafts of this narrative.