Perspectives in Hospital Medicine

Internists are experts in general medicine, skilled at mapping the few hundred ways the human body can go awry onto thousands of diagnoses, and managing the uncertainty inherent in that process. Generalists, almost by definition, consult specialists with their specialty-focused questions; but who does one call for a general consultation about diagnosis if a specific diagnosis remains elusive and the pathology does not fit cleanly into the purview of a consultant? Outside of sage advice from colleagues (usually senior), most medical centers lack a consultation service focused on diagnosis. There is no oracle to seek. In this perspective, we describe our institution’s answer to this problem: the creation of a service for difficult diagnosis based on Socratic principles, particularly the role of iterative hypothesis testing in the process of diagnosis.¹

In 2015, Northwestern Medicine began the Socrates Project, a physician-to-physician consultation service that assists doctors working to diagnose conditions that have so far eluded detection. Our service’s goal is to improve patient care by providing an opinion to the referring physician on diagnostic possibilities for a particular case and ideas to reduce—or at least manage—diagnostic uncertainty.

Most patients referred to the Socrates Project have already undergone an extensive evaluation at top medical centers by experienced clinicians. It would be hubris to assume that we will find a definitive diagnosis in every case; indeed, because of the types of cases referred to our group, it is rare that we find a “Eureka!” diagnosis. When a colleague consults our group, we under-promise in hopes of over-delivering. Instead, we convey to referring physicians that we will conduct a thorough case review and explain our thinking in hopes of uncovering an additional diagnostic avenue, even if that avenue does not ultimately lead to a definitive diagnosis. In addition, the Socrates Project often serves as a broker between consulting services that are deadlocked because of differing diagnostic opinions. We also assist with cases in which a functional disorder is suspected, yet the referring physician is hesitant to diagnose a patient with such a disorder out of concern about missing an important (and possibly obscure) diagnosis.

The Socrates Project receives approximately two consult requests per week, usually from general internists but also from specialists in nearly all disciplines. Around 80% of the referrals are for current inpatients. Our service model is similar to a tumor board, which exists as an interdisciplinary group operating in parallel to the clinical services, to provide consensus-based recommendations. As a result, we act as doctors for doctors, formalizing the curbside consultation. Our usual turnaround time is a week but can be faster for urgent cases. Currently, Socrates Project members, including the faculty leader, volunteer their time and effort at no cost, and there are no charges to patients when physicians consult our group. An overview of the Socrates Project’s personnel and process are outlined in the Figure.

Northwestern’s Chief Medical Residents (CMRs) serve as the fellows for the service, and one of them assumes primary responsibility for each new consultation request the service receives. After obtaining the patient’s case history from the referring provider, the CMR then undertakes a thorough review of the electronic health record and any other available records from other institutions. In the inpatient setting, the CMR performs a new history and physical; phone calls or video conferencing permit history taking for outpatients. In contrast with the standard consultant note, we do not redocument the history, physical, and lab and imaging findings but instead construct a detailed problem list that synthesizes relevant findings into a useful working document.

The service’s faculty leader (BDS) then reviews the problem list with the CMRs to help refine the problem list and begin producing a differential diagnosis during a weekly hour-long meeting. As evidence supports team-based diagnostic collaborations,² the problem list and preliminary differential diagnosis then becomes a shareable document that the CMR or team leader presents to ad hoc general internists, specialists, and the other CMRs. The presentation can be in person, by phone, or e-mail. These ad hoc members, approximately 20 in number and spanning from junior attending physicians to senior clinicians, have volunteered to help the Socrates Project by adding their thoughts on differential diagnoses that explain the problem list and how to move forward with further testing. The ad hoc members have self-identified as clinicians with an interest in medical diagnosis—including surgeons, neurologists, psychiatrists, radiologists, and pathologists—and range in expertise from general internists to subspecialists. Finally, we document our problem list, differential diagnosis, and recommendations in the medical record and discuss the case with the referring team. The service limits its scope of clinical recommendation to diagnosis and avoids commenting on management decisions outside of the use of therapies as empiric diagnostic tests. A sample note is provided as an online Appendix.

Despite our process, we are often left without a satisfying diagnosis. We then are then faced with three possibilities: (1) The diagnosis is identifiable, just not by the physicians involved in the case—we did not think of the diagnosis in our deliberations; (2) The diagnosis is a described condition but without an available test—autoimmune limbic encephalitis associated with an unassayable or unknown auto-antibody, or the acuity of a critically ill patient makes diagnostic testing unreliable or not feasible; (3) The diagnosis has not yet been described by medical science—we are seeing a case of HIV infection in 1971.

With the personnel and process outlined above, we hope to provide recommendations that are useful in guiding a diagnostic workup regardless of which of these three scenarios is applicable. Our flexibility with involving the appropriate specialists in the Socrates Project should minimize the number of patients with a knowable diagnosis that is unknown to us. In the second scenario, our recommendations may rest upon the incorporation of a treatment as a diagnostic test. In the limbic encephalitis example above, a trial of steroids with rapid improvement in the patient’s condition may increase diagnostic certainty. The third scenario is the most difficult to identify. Pattern recognition of similarly presenting patients, keeping ourselves updated on pertinent primary literature, and consideration of advanced diagnostic testing such as exome sequencing and other next-generation sequencing strategies are essential in hoping to characterize a specific clinical syndrome that has yet to be described.

For situations in which our recommendations do not yield a diagnosis, we recognize the role for protocols such as genomic or metagenomic sequencing that assess multiple diagnostic possibilities in parallel without an a priori hypothesis.^3,4 The utility of multi-omics testing in diagnostic workups has been detailed by the Undiagnosed Diseases Network (UDN), which has created a systematic approach to describing new syndromes with the aid of metabolomic and genomic profiling.⁵ It is important to note that even with the resources available to the UDN, the diagnosis rate is 35%, emphasizing that in the majority of diagnosis-refractory cases, a diagnosis will not be found. This low diagnosis rate underscores the need for continued inquiry and cataloging of cases and data for further review or synthesis as the body of medical knowledge continues to expand. For these reasons, we have a follow-up system in place, which involves the assigned CMR regularly reviewing the chart and reporting during our weekly meetings. We make phone calls to patients and providers for cases that appear to be lost to follow-up.

We recognize several important limitations to our care model that may represent barriers to establishing, maintaining, and evaluating a similar service at other institutions. For example, there are limitations and benefits of the CMR as point person for managing our consultations. While they are admittedly junior colleagues with limited experience, CMRs tend to be among the best-read and up-to-date clinicians in the hospital by virtue of their recent general-medicine training and identification as a top clinician and leader. Moreover, in their role with the Socrates Project, CMRs have more time to think, talk with patients, and review the medical record than other clinicians, who may be under pressure to see an increasing number of patients while billing at higher levels. Indeed, the Socrates Project CMRs have, on a number of occasions, been the team members who find the piece of data that no one else thought relevant.

Another factor that may limit establishment of a similar team at other institutions is our volunteer-based model. The Socrates Project members volunteer because they love clinical medicine and serve on the team without remuneration for professional effort. With the CMR role as a notable exception, pressure from achieving relative value unit targets, obtaining grant funding, and publishing primary research publications in their field may limit this care model, particularly when shifting from a clinical-only activity to one that also formally investigates the service’s process and outcomes.

Beyond our clinical objective, we hope that the Socrates Project will further the discovery and description of previously unrecognized disease processes. To that end, we are pursuing an institutional review board-approved protocol to perform a rigorous assessment of the Socrates Project’s process and outcomes, including a cataloging of case archetypes and the time to definitive diagnosis if a diagnosis is established. As we continue to collect data, increasing our referral network may also lead to refinement and improvement in diagnostic processes and outcomes. Over time, we expect that the diagnostic resources available to us will evolve. Utilizing collective intelligence has been shown to improve diagnostic accuracy,⁶ and emerging artificial intelligence technologies may improve diagnostic performance as well.^7,8 Most importantly, through this endeavor, we hope to serve less as an oracle and more as a humble Socratic consultant for clinicians working to reduce diagnostic uncertainty for their patients.

Acknowledgments

The authors wish to thank the Northwestern University Chief Medical Residents, 2015-present, for their tireless efforts in support of the Socrates Project.

Internists are experts in general medicine, skilled at mapping the few hundred ways the human body can go awry onto thousands of diagnoses, and managing the uncertainty inherent in that process. Generalists, almost by definition, consult specialists with their specialty-focused questions; but who does one call for a general consultation about diagnosis if a specific diagnosis remains elusive and the pathology does not fit cleanly into the purview of a consultant? Outside of sage advice from colleagues (usually senior), most medical centers lack a consultation service focused on diagnosis. There is no oracle to seek. In this perspective, we describe our institution’s answer to this problem: the creation of a service for difficult diagnosis based on Socratic principles, particularly the role of iterative hypothesis testing in the process of diagnosis.¹

In 2015, Northwestern Medicine began the Socrates Project, a physician-to-physician consultation service that assists doctors working to diagnose conditions that have so far eluded detection. Our service’s goal is to improve patient care by providing an opinion to the referring physician on diagnostic possibilities for a particular case and ideas to reduce—or at least manage—diagnostic uncertainty.

Most patients referred to the Socrates Project have already undergone an extensive evaluation at top medical centers by experienced clinicians. It would be hubris to assume that we will find a definitive diagnosis in every case; indeed, because of the types of cases referred to our group, it is rare that we find a “Eureka!” diagnosis. When a colleague consults our group, we under-promise in hopes of over-delivering. Instead, we convey to referring physicians that we will conduct a thorough case review and explain our thinking in hopes of uncovering an additional diagnostic avenue, even if that avenue does not ultimately lead to a definitive diagnosis. In addition, the Socrates Project often serves as a broker between consulting services that are deadlocked because of differing diagnostic opinions. We also assist with cases in which a functional disorder is suspected, yet the referring physician is hesitant to diagnose a patient with such a disorder out of concern about missing an important (and possibly obscure) diagnosis.

The Socrates Project receives approximately two consult requests per week, usually from general internists but also from specialists in nearly all disciplines. Around 80% of the referrals are for current inpatients. Our service model is similar to a tumor board, which exists as an interdisciplinary group operating in parallel to the clinical services, to provide consensus-based recommendations. As a result, we act as doctors for doctors, formalizing the curbside consultation. Our usual turnaround time is a week but can be faster for urgent cases. Currently, Socrates Project members, including the faculty leader, volunteer their time and effort at no cost, and there are no charges to patients when physicians consult our group. An overview of the Socrates Project’s personnel and process are outlined in the Figure.

Northwestern’s Chief Medical Residents (CMRs) serve as the fellows for the service, and one of them assumes primary responsibility for each new consultation request the service receives. After obtaining the patient’s case history from the referring provider, the CMR then undertakes a thorough review of the electronic health record and any other available records from other institutions. In the inpatient setting, the CMR performs a new history and physical; phone calls or video conferencing permit history taking for outpatients. In contrast with the standard consultant note, we do not redocument the history, physical, and lab and imaging findings but instead construct a detailed problem list that synthesizes relevant findings into a useful working document.

The service’s faculty leader (BDS) then reviews the problem list with the CMRs to help refine the problem list and begin producing a differential diagnosis during a weekly hour-long meeting. As evidence supports team-based diagnostic collaborations,² the problem list and preliminary differential diagnosis then becomes a shareable document that the CMR or team leader presents to ad hoc general internists, specialists, and the other CMRs. The presentation can be in person, by phone, or e-mail. These ad hoc members, approximately 20 in number and spanning from junior attending physicians to senior clinicians, have volunteered to help the Socrates Project by adding their thoughts on differential diagnoses that explain the problem list and how to move forward with further testing. The ad hoc members have self-identified as clinicians with an interest in medical diagnosis—including surgeons, neurologists, psychiatrists, radiologists, and pathologists—and range in expertise from general internists to subspecialists. Finally, we document our problem list, differential diagnosis, and recommendations in the medical record and discuss the case with the referring team. The service limits its scope of clinical recommendation to diagnosis and avoids commenting on management decisions outside of the use of therapies as empiric diagnostic tests. A sample note is provided as an online Appendix.

Despite our process, we are often left without a satisfying diagnosis. We then are then faced with three possibilities: (1) The diagnosis is identifiable, just not by the physicians involved in the case—we did not think of the diagnosis in our deliberations; (2) The diagnosis is a described condition but without an available test—autoimmune limbic encephalitis associated with an unassayable or unknown auto-antibody, or the acuity of a critically ill patient makes diagnostic testing unreliable or not feasible; (3) The diagnosis has not yet been described by medical science—we are seeing a case of HIV infection in 1971.

With the personnel and process outlined above, we hope to provide recommendations that are useful in guiding a diagnostic workup regardless of which of these three scenarios is applicable. Our flexibility with involving the appropriate specialists in the Socrates Project should minimize the number of patients with a knowable diagnosis that is unknown to us. In the second scenario, our recommendations may rest upon the incorporation of a treatment as a diagnostic test. In the limbic encephalitis example above, a trial of steroids with rapid improvement in the patient’s condition may increase diagnostic certainty. The third scenario is the most difficult to identify. Pattern recognition of similarly presenting patients, keeping ourselves updated on pertinent primary literature, and consideration of advanced diagnostic testing such as exome sequencing and other next-generation sequencing strategies are essential in hoping to characterize a specific clinical syndrome that has yet to be described.

For situations in which our recommendations do not yield a diagnosis, we recognize the role for protocols such as genomic or metagenomic sequencing that assess multiple diagnostic possibilities in parallel without an a priori hypothesis.^3,4 The utility of multi-omics testing in diagnostic workups has been detailed by the Undiagnosed Diseases Network (UDN), which has created a systematic approach to describing new syndromes with the aid of metabolomic and genomic profiling.⁵ It is important to note that even with the resources available to the UDN, the diagnosis rate is 35%, emphasizing that in the majority of diagnosis-refractory cases, a diagnosis will not be found. This low diagnosis rate underscores the need for continued inquiry and cataloging of cases and data for further review or synthesis as the body of medical knowledge continues to expand. For these reasons, we have a follow-up system in place, which involves the assigned CMR regularly reviewing the chart and reporting during our weekly meetings. We make phone calls to patients and providers for cases that appear to be lost to follow-up.

We recognize several important limitations to our care model that may represent barriers to establishing, maintaining, and evaluating a similar service at other institutions. For example, there are limitations and benefits of the CMR as point person for managing our consultations. While they are admittedly junior colleagues with limited experience, CMRs tend to be among the best-read and up-to-date clinicians in the hospital by virtue of their recent general-medicine training and identification as a top clinician and leader. Moreover, in their role with the Socrates Project, CMRs have more time to think, talk with patients, and review the medical record than other clinicians, who may be under pressure to see an increasing number of patients while billing at higher levels. Indeed, the Socrates Project CMRs have, on a number of occasions, been the team members who find the piece of data that no one else thought relevant.

Another factor that may limit establishment of a similar team at other institutions is our volunteer-based model. The Socrates Project members volunteer because they love clinical medicine and serve on the team without remuneration for professional effort. With the CMR role as a notable exception, pressure from achieving relative value unit targets, obtaining grant funding, and publishing primary research publications in their field may limit this care model, particularly when shifting from a clinical-only activity to one that also formally investigates the service’s process and outcomes.

Beyond our clinical objective, we hope that the Socrates Project will further the discovery and description of previously unrecognized disease processes. To that end, we are pursuing an institutional review board-approved protocol to perform a rigorous assessment of the Socrates Project’s process and outcomes, including a cataloging of case archetypes and the time to definitive diagnosis if a diagnosis is established. As we continue to collect data, increasing our referral network may also lead to refinement and improvement in diagnostic processes and outcomes. Over time, we expect that the diagnostic resources available to us will evolve. Utilizing collective intelligence has been shown to improve diagnostic accuracy,⁶ and emerging artificial intelligence technologies may improve diagnostic performance as well.^7,8 Most importantly, through this endeavor, we hope to serve less as an oracle and more as a humble Socratic consultant for clinicians working to reduce diagnostic uncertainty for their patients.

Acknowledgments

The authors wish to thank the Northwestern University Chief Medical Residents, 2015-present, for their tireless efforts in support of the Socrates Project.

Internists are experts in general medicine, skilled at mapping the few hundred ways the human body can go awry onto thousands of diagnoses, and managing the uncertainty inherent in that process. Generalists, almost by definition, consult specialists with their specialty-focused questions; but who does one call for a general consultation about diagnosis if a specific diagnosis remains elusive and the pathology does not fit cleanly into the purview of a consultant? Outside of sage advice from colleagues (usually senior), most medical centers lack a consultation service focused on diagnosis. There is no oracle to seek. In this perspective, we describe our institution’s answer to this problem: the creation of a service for difficult diagnosis based on Socratic principles, particularly the role of iterative hypothesis testing in the process of diagnosis.¹

In 2015, Northwestern Medicine began the Socrates Project, a physician-to-physician consultation service that assists doctors working to diagnose conditions that have so far eluded detection. Our service’s goal is to improve patient care by providing an opinion to the referring physician on diagnostic possibilities for a particular case and ideas to reduce—or at least manage—diagnostic uncertainty.

Most patients referred to the Socrates Project have already undergone an extensive evaluation at top medical centers by experienced clinicians. It would be hubris to assume that we will find a definitive diagnosis in every case; indeed, because of the types of cases referred to our group, it is rare that we find a “Eureka!” diagnosis. When a colleague consults our group, we under-promise in hopes of over-delivering. Instead, we convey to referring physicians that we will conduct a thorough case review and explain our thinking in hopes of uncovering an additional diagnostic avenue, even if that avenue does not ultimately lead to a definitive diagnosis. In addition, the Socrates Project often serves as a broker between consulting services that are deadlocked because of differing diagnostic opinions. We also assist with cases in which a functional disorder is suspected, yet the referring physician is hesitant to diagnose a patient with such a disorder out of concern about missing an important (and possibly obscure) diagnosis.

The Socrates Project receives approximately two consult requests per week, usually from general internists but also from specialists in nearly all disciplines. Around 80% of the referrals are for current inpatients. Our service model is similar to a tumor board, which exists as an interdisciplinary group operating in parallel to the clinical services, to provide consensus-based recommendations. As a result, we act as doctors for doctors, formalizing the curbside consultation. Our usual turnaround time is a week but can be faster for urgent cases. Currently, Socrates Project members, including the faculty leader, volunteer their time and effort at no cost, and there are no charges to patients when physicians consult our group. An overview of the Socrates Project’s personnel and process are outlined in the Figure.

Northwestern’s Chief Medical Residents (CMRs) serve as the fellows for the service, and one of them assumes primary responsibility for each new consultation request the service receives. After obtaining the patient’s case history from the referring provider, the CMR then undertakes a thorough review of the electronic health record and any other available records from other institutions. In the inpatient setting, the CMR performs a new history and physical; phone calls or video conferencing permit history taking for outpatients. In contrast with the standard consultant note, we do not redocument the history, physical, and lab and imaging findings but instead construct a detailed problem list that synthesizes relevant findings into a useful working document.

The service’s faculty leader (BDS) then reviews the problem list with the CMRs to help refine the problem list and begin producing a differential diagnosis during a weekly hour-long meeting. As evidence supports team-based diagnostic collaborations,² the problem list and preliminary differential diagnosis then becomes a shareable document that the CMR or team leader presents to ad hoc general internists, specialists, and the other CMRs. The presentation can be in person, by phone, or e-mail. These ad hoc members, approximately 20 in number and spanning from junior attending physicians to senior clinicians, have volunteered to help the Socrates Project by adding their thoughts on differential diagnoses that explain the problem list and how to move forward with further testing. The ad hoc members have self-identified as clinicians with an interest in medical diagnosis—including surgeons, neurologists, psychiatrists, radiologists, and pathologists—and range in expertise from general internists to subspecialists. Finally, we document our problem list, differential diagnosis, and recommendations in the medical record and discuss the case with the referring team. The service limits its scope of clinical recommendation to diagnosis and avoids commenting on management decisions outside of the use of therapies as empiric diagnostic tests. A sample note is provided as an online Appendix.

Despite our process, we are often left without a satisfying diagnosis. We then are then faced with three possibilities: (1) The diagnosis is identifiable, just not by the physicians involved in the case—we did not think of the diagnosis in our deliberations; (2) The diagnosis is a described condition but without an available test—autoimmune limbic encephalitis associated with an unassayable or unknown auto-antibody, or the acuity of a critically ill patient makes diagnostic testing unreliable or not feasible; (3) The diagnosis has not yet been described by medical science—we are seeing a case of HIV infection in 1971.

With the personnel and process outlined above, we hope to provide recommendations that are useful in guiding a diagnostic workup regardless of which of these three scenarios is applicable. Our flexibility with involving the appropriate specialists in the Socrates Project should minimize the number of patients with a knowable diagnosis that is unknown to us. In the second scenario, our recommendations may rest upon the incorporation of a treatment as a diagnostic test. In the limbic encephalitis example above, a trial of steroids with rapid improvement in the patient’s condition may increase diagnostic certainty. The third scenario is the most difficult to identify. Pattern recognition of similarly presenting patients, keeping ourselves updated on pertinent primary literature, and consideration of advanced diagnostic testing such as exome sequencing and other next-generation sequencing strategies are essential in hoping to characterize a specific clinical syndrome that has yet to be described.

For situations in which our recommendations do not yield a diagnosis, we recognize the role for protocols such as genomic or metagenomic sequencing that assess multiple diagnostic possibilities in parallel without an a priori hypothesis.^3,4 The utility of multi-omics testing in diagnostic workups has been detailed by the Undiagnosed Diseases Network (UDN), which has created a systematic approach to describing new syndromes with the aid of metabolomic and genomic profiling.⁵ It is important to note that even with the resources available to the UDN, the diagnosis rate is 35%, emphasizing that in the majority of diagnosis-refractory cases, a diagnosis will not be found. This low diagnosis rate underscores the need for continued inquiry and cataloging of cases and data for further review or synthesis as the body of medical knowledge continues to expand. For these reasons, we have a follow-up system in place, which involves the assigned CMR regularly reviewing the chart and reporting during our weekly meetings. We make phone calls to patients and providers for cases that appear to be lost to follow-up.

We recognize several important limitations to our care model that may represent barriers to establishing, maintaining, and evaluating a similar service at other institutions. For example, there are limitations and benefits of the CMR as point person for managing our consultations. While they are admittedly junior colleagues with limited experience, CMRs tend to be among the best-read and up-to-date clinicians in the hospital by virtue of their recent general-medicine training and identification as a top clinician and leader. Moreover, in their role with the Socrates Project, CMRs have more time to think, talk with patients, and review the medical record than other clinicians, who may be under pressure to see an increasing number of patients while billing at higher levels. Indeed, the Socrates Project CMRs have, on a number of occasions, been the team members who find the piece of data that no one else thought relevant.

Another factor that may limit establishment of a similar team at other institutions is our volunteer-based model. The Socrates Project members volunteer because they love clinical medicine and serve on the team without remuneration for professional effort. With the CMR role as a notable exception, pressure from achieving relative value unit targets, obtaining grant funding, and publishing primary research publications in their field may limit this care model, particularly when shifting from a clinical-only activity to one that also formally investigates the service’s process and outcomes.

Beyond our clinical objective, we hope that the Socrates Project will further the discovery and description of previously unrecognized disease processes. To that end, we are pursuing an institutional review board-approved protocol to perform a rigorous assessment of the Socrates Project’s process and outcomes, including a cataloging of case archetypes and the time to definitive diagnosis if a diagnosis is established. As we continue to collect data, increasing our referral network may also lead to refinement and improvement in diagnostic processes and outcomes. Over time, we expect that the diagnostic resources available to us will evolve. Utilizing collective intelligence has been shown to improve diagnostic accuracy,⁶ and emerging artificial intelligence technologies may improve diagnostic performance as well.^7,8 Most importantly, through this endeavor, we hope to serve less as an oracle and more as a humble Socratic consultant for clinicians working to reduce diagnostic uncertainty for their patients.

Acknowledgments

The authors wish to thank the Northwestern University Chief Medical Residents, 2015-present, for their tireless efforts in support of the Socrates Project.

In 2017, the death toll from drug overdoses reached a record high, killing more Americans than the entire Vietnam War or the HIV/AIDS epidemic at its peak.¹ Up to one-quarter of hospitalized patients have a substance use disorder (SUD) and SUD-related^2,3 hospitalizations are surging. People with SUD have longer hospital stays, higher costs, and more readmissions.^3,4 While the burden of SUD is staggering, it is far from hopeless. There are multiple evidence-based and highly effective interventions to treat SUD, including medications, behavioral interventions, and harm reduction strategies.

Hospitalization can be a reachable moment to initiate and coordinate addictions care.⁵ Hospital-based addictions care has the potential to engage sicker, highly vulnerable patients, many who are not engaged in primary care or outpatient addictions care.⁶ Studied effects of hospital-based addictions care include improved SUD treatment engagement, reduced alcohol and drug use, lower hospital readmissions, and improved provider experience.^7-9

Most hospitals, however, do not treat SUD during hospitalization and do not connect people to treatment after discharge. Hospitals may lack staffing or financial resources to implement addiction care, may believe that SUDs are an outpatient concern, may want to avoid caring for people with SUD, or may simply not know where to begin. Whatever the reason, unaddressed SUD can lead to untreated withdrawal, disruptive patient behaviors, failure to complete recommended medical therapy, high rates of against medical advice discharge, poor patient experience, and widespread provider distress.⁸

Hospitalists—individually and collectively—are uniquely positioned to address this gap. By treating addiction effectively and compassionately, hospitalists can engage patients, improve care, improve patient and provider experience, and lower costs. This paper is a call to action that describes the current state of hospital-based addictions care, outlines key challenges to implementing SUD care in the hospital, debunks common misconceptions, and identifies actionable steps for hospitalists, hospital leaders, and hospitalist organizations.

Hospital-based addiction medicine consult services are emerging; they include a range of models, with variations in how patients are identified, team composition, service availability, and financing.¹⁰ Existing addiction medicine consult services commonly offer SUD assessments, psychological intervention, medical management of SUDs (eg, initiating methadone or buprenorphine), medical pain management, and linkage to SUD care after hospitalization. Some services also explicitly integrate harm reduction principles (eg, naloxone distribution, safe injection education, permitting patients to smoke).¹¹ Additional consult service activities include hospital-wide SUD education, and creation and implementation of hospital guidance documents (eg, methadone policies).¹⁰ Some consult services utilize only physicians, while others include interprofessional providers, such as nurses, social workers, and peers with lived experience of addiction. Whereas addiction medicine physicians staff some consult services, hospitalists with less formal addiction credentials staff others.

Broadly, hospital-based addictions care cannot depend solely on consult services. Just as not all hospitals have cardiology consult services, not all hospitals will have addiction consult services. As such, hospitalists can play an even greater role by implementing order sets and guidelines, supporting partnerships with community SUD treatment, and independently initiating evidence-based medications.

Pervasive individual and structural stigmas¹² are perhaps the most critical barriers to incorporating addiction medicine into routine hospital practice, and they are both cause and consequence of our system failures. Most medical schools and residencies lack SUD training, which means that the understanding of addiction as a moral deficiency or lack of willpower may remain unchallenged. Stigma surrounding SUDs contributes to hospitalists’ and hospital leaders’ aversion to treating patients with SUD, and to fears that providing quality SUD care will attract patients suffering from these conditions.

Recent national efforts have focused on the problem of opioid overprescribing. Without an equal emphasis on treatment, this focus can lead to undertreatment of pain and/or opioid use disorder in hospitalized patients, particularly since most hospitalists have little to no training in diagnosing SUD, prescribing life-saving medications for opioid use disorder, or managing acute pain in patients with SUD. The focus on overprescribing also diverts attention away from trends involving stimulants,² fentanyl contamination of the drug supply,¹³ and alcohol, all of which have important implications for the care of hospitalized adults.

Hospital policies are often not grounded in evidence (eg, recommending clonidine for first-line treatment of opioid withdrawal and not buprenorphine/methadone), and there are widespread misconceptions about perceived legal barriers to treating opioid use disorder in the hospital, which is both safe and legal.¹⁰ People with SUD may be unjustly viewed through a criminal justice lens. Policies focused on controlling visitors and conducting room searches disproportionately burden people with SUD, which may create further harms through reinforcing negative provider cognitive biases about SUDs. Finally, hospitals may lack inpatient social work and pharmacy supports, and they rarely have pathways to connect people to SUD care after discharge.

Funding remains a widespread challenge. While some hospital administrators support addiction medicine services because of the pressing medical need and public health crisis, most services depend on billing or demonstrated savings through reduced hospital days or readmissions.

Individual hospitalists, hospitalist leaders, and hospitalist organizations can engage by improving individual practice, driving systems change, and through advocacy and policy change (Table).

Individual Hospitalists

Providing basic addiction medicine care should be a core competency for all hospitalists, just as every hospitalist can initiate a goals-of-care conversation or prescribe insulin. For opioid use disorder, hospitalists should treat withdrawal and offer treatment initiation with opioid agonist therapy (ie, methadone, buprenorphine), which reduces mortality by over half. Commonly, hospitalized patients are subjected to harmful, nonevidence-based treatments, such as mandated rapid methadone tapers,²⁵ which can lead to undertreated withdrawal, increased pain, and opioid cravings. This increases patients’ risk for overdose after discharge and precludes them from receiving life-saving, evidence-based methadone maintenance, or buprenorphine treatment. Though widely misunderstood, prescribing methadone in the hospital is legal, and providers need no special waiver to prescribe buprenorphine during admission. Current laws require that hospitalists have a waiver to prescribe buprenorphine at discharge and prohibit hospitalists (or anyone outside of an opioid treatment program) from prescribing methadone for the treatment of opioid use disorder at discharge. Further, hospitalists should offer medication for alcohol use disorder (eg, naltrexone) and be good stewards of opioids during hospitalization, avoiding intravenous opioids where appropriate and curbing excessive prescribing at discharge. Given high rates of overdose and fentanyl contamination of stimulants, opioids, and benzodiazepines, hospitalists should prescribe naloxone at discharge to every patient with SUD, on chronic opioids, or who uses any nonmedical substances.

Resources exist for individual hospitalists seeking mentorship or additional training (Table). Though not necessary for in-hospital prescribing, hospitalists can obtain a waiver to prescribe buprenorphine at discharge (commonly called the X-waiver). To qualify, physicians must complete eight hours of accredited training (online and/or in-person), after which they must request a waiver from the Drug Enforcement Administration. Advanced-practice practitioners must complete 24 hours of training. Many have argued that policymakers should end this waiver requirement.²⁶ While we support efforts to “X the X” and urgently expand treatment access, additional training can enrich providers’ knowledge and confidence to prescribe buprenorphine, and is a relatively simple way that all hospitalists could act. Finally, by treating addiction and modeling patient-centered addictions care, hospitalists can legitimize and destigmatize the disease of addiction,⁸ and have the potential to mentor and train students, residents, nurses, and other staff.²⁷

Hospitalist Leaders

As leaders, hospitalists can play a key role in promoting hospital-based addictions care and tailoring solutions to meet local needs. Leaders can promote a cultural shift away from stigma, and promote evidence-based, life-saving care. Hospitalist leaders could require all hospitalists to obtain buprenorphine waivers. Leaders could initiate quality improvement projects related to SUD service delivery, develop policies that support inpatient SUD treatment, develop order sets for medication initiation, engage community substance use treatment partners, build pathways to timely addiction care after discharge, and champion development of addiction medicine consult services.

Hospitalist leaders can reference open-source guidelines, order sets, assessment and treatment tools, patient materials, pharmacy and therapeutics committee materials, and other resources for implementing services for hospitalized patients with SUD (Table).^21,22 Hospitalist leaders who understand financial and quality drivers can also champion the business and quality case for hospital-based addictions care, and help pursue local and national funding opportunities.

Hospitalist Organizations

Hospitalist societies could provide training at regional and national conferences to upskill hospitalists to care for people with SUD; support addiction medicine interest groups; and partner with addiction medicine societies, harm reduction organizations, and organizations focused on trauma-informed care. They could endorse practice guidelines and position statements describing the crucial role of hospitalists in addressing the overdose crisis and offering medication for addiction (Table). Hospitalist organizations can engage national and state hospital associations, lobby medical specialties to include addiction medicine competencies in board certification requirements, and advocate with governmental leaders to reduce barriers that restrict treatment access such as the X-waiver.

Regardless of whether a hospitalist is serving as an individual provider, a hospitalist leader, or as part of a hospitalist organization, hospitalists can take critical steps to advance the care of people with SUD. These steps shift the culture of hospitals from one where patients are afraid to discuss their substance use, to one that creates space for connection, treatment engagement, and healing. By starting medications, utilizing widely accessible resources, and collaborating with community treatment and harm reduction organizations, each one of us can play a part in addressing the epidemic.

Acknowledgments

The authors thank Alisa Patten for help preparing this manuscript. Dr. Englander would like to thank Dr. David Bangsberg and Dr. Christina Nicolaidis for their mentorship.

In 2017, the death toll from drug overdoses reached a record high, killing more Americans than the entire Vietnam War or the HIV/AIDS epidemic at its peak.¹ Up to one-quarter of hospitalized patients have a substance use disorder (SUD) and SUD-related^2,3 hospitalizations are surging. People with SUD have longer hospital stays, higher costs, and more readmissions.^3,4 While the burden of SUD is staggering, it is far from hopeless. There are multiple evidence-based and highly effective interventions to treat SUD, including medications, behavioral interventions, and harm reduction strategies.

Hospitalization can be a reachable moment to initiate and coordinate addictions care.⁵ Hospital-based addictions care has the potential to engage sicker, highly vulnerable patients, many who are not engaged in primary care or outpatient addictions care.⁶ Studied effects of hospital-based addictions care include improved SUD treatment engagement, reduced alcohol and drug use, lower hospital readmissions, and improved provider experience.^7-9

Most hospitals, however, do not treat SUD during hospitalization and do not connect people to treatment after discharge. Hospitals may lack staffing or financial resources to implement addiction care, may believe that SUDs are an outpatient concern, may want to avoid caring for people with SUD, or may simply not know where to begin. Whatever the reason, unaddressed SUD can lead to untreated withdrawal, disruptive patient behaviors, failure to complete recommended medical therapy, high rates of against medical advice discharge, poor patient experience, and widespread provider distress.⁸

Hospitalists—individually and collectively—are uniquely positioned to address this gap. By treating addiction effectively and compassionately, hospitalists can engage patients, improve care, improve patient and provider experience, and lower costs. This paper is a call to action that describes the current state of hospital-based addictions care, outlines key challenges to implementing SUD care in the hospital, debunks common misconceptions, and identifies actionable steps for hospitalists, hospital leaders, and hospitalist organizations.

Hospital-based addiction medicine consult services are emerging; they include a range of models, with variations in how patients are identified, team composition, service availability, and financing.¹⁰ Existing addiction medicine consult services commonly offer SUD assessments, psychological intervention, medical management of SUDs (eg, initiating methadone or buprenorphine), medical pain management, and linkage to SUD care after hospitalization. Some services also explicitly integrate harm reduction principles (eg, naloxone distribution, safe injection education, permitting patients to smoke).¹¹ Additional consult service activities include hospital-wide SUD education, and creation and implementation of hospital guidance documents (eg, methadone policies).¹⁰ Some consult services utilize only physicians, while others include interprofessional providers, such as nurses, social workers, and peers with lived experience of addiction. Whereas addiction medicine physicians staff some consult services, hospitalists with less formal addiction credentials staff others.

Broadly, hospital-based addictions care cannot depend solely on consult services. Just as not all hospitals have cardiology consult services, not all hospitals will have addiction consult services. As such, hospitalists can play an even greater role by implementing order sets and guidelines, supporting partnerships with community SUD treatment, and independently initiating evidence-based medications.

Pervasive individual and structural stigmas¹² are perhaps the most critical barriers to incorporating addiction medicine into routine hospital practice, and they are both cause and consequence of our system failures. Most medical schools and residencies lack SUD training, which means that the understanding of addiction as a moral deficiency or lack of willpower may remain unchallenged. Stigma surrounding SUDs contributes to hospitalists’ and hospital leaders’ aversion to treating patients with SUD, and to fears that providing quality SUD care will attract patients suffering from these conditions.

Recent national efforts have focused on the problem of opioid overprescribing. Without an equal emphasis on treatment, this focus can lead to undertreatment of pain and/or opioid use disorder in hospitalized patients, particularly since most hospitalists have little to no training in diagnosing SUD, prescribing life-saving medications for opioid use disorder, or managing acute pain in patients with SUD. The focus on overprescribing also diverts attention away from trends involving stimulants,² fentanyl contamination of the drug supply,¹³ and alcohol, all of which have important implications for the care of hospitalized adults.

Hospital policies are often not grounded in evidence (eg, recommending clonidine for first-line treatment of opioid withdrawal and not buprenorphine/methadone), and there are widespread misconceptions about perceived legal barriers to treating opioid use disorder in the hospital, which is both safe and legal.¹⁰ People with SUD may be unjustly viewed through a criminal justice lens. Policies focused on controlling visitors and conducting room searches disproportionately burden people with SUD, which may create further harms through reinforcing negative provider cognitive biases about SUDs. Finally, hospitals may lack inpatient social work and pharmacy supports, and they rarely have pathways to connect people to SUD care after discharge.

Funding remains a widespread challenge. While some hospital administrators support addiction medicine services because of the pressing medical need and public health crisis, most services depend on billing or demonstrated savings through reduced hospital days or readmissions.

Individual hospitalists, hospitalist leaders, and hospitalist organizations can engage by improving individual practice, driving systems change, and through advocacy and policy change (Table).

Individual Hospitalists

Providing basic addiction medicine care should be a core competency for all hospitalists, just as every hospitalist can initiate a goals-of-care conversation or prescribe insulin. For opioid use disorder, hospitalists should treat withdrawal and offer treatment initiation with opioid agonist therapy (ie, methadone, buprenorphine), which reduces mortality by over half. Commonly, hospitalized patients are subjected to harmful, nonevidence-based treatments, such as mandated rapid methadone tapers,²⁵ which can lead to undertreated withdrawal, increased pain, and opioid cravings. This increases patients’ risk for overdose after discharge and precludes them from receiving life-saving, evidence-based methadone maintenance, or buprenorphine treatment. Though widely misunderstood, prescribing methadone in the hospital is legal, and providers need no special waiver to prescribe buprenorphine during admission. Current laws require that hospitalists have a waiver to prescribe buprenorphine at discharge and prohibit hospitalists (or anyone outside of an opioid treatment program) from prescribing methadone for the treatment of opioid use disorder at discharge. Further, hospitalists should offer medication for alcohol use disorder (eg, naltrexone) and be good stewards of opioids during hospitalization, avoiding intravenous opioids where appropriate and curbing excessive prescribing at discharge. Given high rates of overdose and fentanyl contamination of stimulants, opioids, and benzodiazepines, hospitalists should prescribe naloxone at discharge to every patient with SUD, on chronic opioids, or who uses any nonmedical substances.

Resources exist for individual hospitalists seeking mentorship or additional training (Table). Though not necessary for in-hospital prescribing, hospitalists can obtain a waiver to prescribe buprenorphine at discharge (commonly called the X-waiver). To qualify, physicians must complete eight hours of accredited training (online and/or in-person), after which they must request a waiver from the Drug Enforcement Administration. Advanced-practice practitioners must complete 24 hours of training. Many have argued that policymakers should end this waiver requirement.²⁶ While we support efforts to “X the X” and urgently expand treatment access, additional training can enrich providers’ knowledge and confidence to prescribe buprenorphine, and is a relatively simple way that all hospitalists could act. Finally, by treating addiction and modeling patient-centered addictions care, hospitalists can legitimize and destigmatize the disease of addiction,⁸ and have the potential to mentor and train students, residents, nurses, and other staff.²⁷

Hospitalist Leaders

As leaders, hospitalists can play a key role in promoting hospital-based addictions care and tailoring solutions to meet local needs. Leaders can promote a cultural shift away from stigma, and promote evidence-based, life-saving care. Hospitalist leaders could require all hospitalists to obtain buprenorphine waivers. Leaders could initiate quality improvement projects related to SUD service delivery, develop policies that support inpatient SUD treatment, develop order sets for medication initiation, engage community substance use treatment partners, build pathways to timely addiction care after discharge, and champion development of addiction medicine consult services.

Hospitalist leaders can reference open-source guidelines, order sets, assessment and treatment tools, patient materials, pharmacy and therapeutics committee materials, and other resources for implementing services for hospitalized patients with SUD (Table).^21,22 Hospitalist leaders who understand financial and quality drivers can also champion the business and quality case for hospital-based addictions care, and help pursue local and national funding opportunities.

Hospitalist Organizations

Hospitalist societies could provide training at regional and national conferences to upskill hospitalists to care for people with SUD; support addiction medicine interest groups; and partner with addiction medicine societies, harm reduction organizations, and organizations focused on trauma-informed care. They could endorse practice guidelines and position statements describing the crucial role of hospitalists in addressing the overdose crisis and offering medication for addiction (Table). Hospitalist organizations can engage national and state hospital associations, lobby medical specialties to include addiction medicine competencies in board certification requirements, and advocate with governmental leaders to reduce barriers that restrict treatment access such as the X-waiver.

Regardless of whether a hospitalist is serving as an individual provider, a hospitalist leader, or as part of a hospitalist organization, hospitalists can take critical steps to advance the care of people with SUD. These steps shift the culture of hospitals from one where patients are afraid to discuss their substance use, to one that creates space for connection, treatment engagement, and healing. By starting medications, utilizing widely accessible resources, and collaborating with community treatment and harm reduction organizations, each one of us can play a part in addressing the epidemic.

Acknowledgments

The authors thank Alisa Patten for help preparing this manuscript. Dr. Englander would like to thank Dr. David Bangsberg and Dr. Christina Nicolaidis for their mentorship.

In 2017, the death toll from drug overdoses reached a record high, killing more Americans than the entire Vietnam War or the HIV/AIDS epidemic at its peak.¹ Up to one-quarter of hospitalized patients have a substance use disorder (SUD) and SUD-related^2,3 hospitalizations are surging. People with SUD have longer hospital stays, higher costs, and more readmissions.^3,4 While the burden of SUD is staggering, it is far from hopeless. There are multiple evidence-based and highly effective interventions to treat SUD, including medications, behavioral interventions, and harm reduction strategies.

Hospitalization can be a reachable moment to initiate and coordinate addictions care.⁵ Hospital-based addictions care has the potential to engage sicker, highly vulnerable patients, many who are not engaged in primary care or outpatient addictions care.⁶ Studied effects of hospital-based addictions care include improved SUD treatment engagement, reduced alcohol and drug use, lower hospital readmissions, and improved provider experience.^7-9

Most hospitals, however, do not treat SUD during hospitalization and do not connect people to treatment after discharge. Hospitals may lack staffing or financial resources to implement addiction care, may believe that SUDs are an outpatient concern, may want to avoid caring for people with SUD, or may simply not know where to begin. Whatever the reason, unaddressed SUD can lead to untreated withdrawal, disruptive patient behaviors, failure to complete recommended medical therapy, high rates of against medical advice discharge, poor patient experience, and widespread provider distress.⁸

Hospitalists—individually and collectively—are uniquely positioned to address this gap. By treating addiction effectively and compassionately, hospitalists can engage patients, improve care, improve patient and provider experience, and lower costs. This paper is a call to action that describes the current state of hospital-based addictions care, outlines key challenges to implementing SUD care in the hospital, debunks common misconceptions, and identifies actionable steps for hospitalists, hospital leaders, and hospitalist organizations.

Hospital-based addiction medicine consult services are emerging; they include a range of models, with variations in how patients are identified, team composition, service availability, and financing.¹⁰ Existing addiction medicine consult services commonly offer SUD assessments, psychological intervention, medical management of SUDs (eg, initiating methadone or buprenorphine), medical pain management, and linkage to SUD care after hospitalization. Some services also explicitly integrate harm reduction principles (eg, naloxone distribution, safe injection education, permitting patients to smoke).¹¹ Additional consult service activities include hospital-wide SUD education, and creation and implementation of hospital guidance documents (eg, methadone policies).¹⁰ Some consult services utilize only physicians, while others include interprofessional providers, such as nurses, social workers, and peers with lived experience of addiction. Whereas addiction medicine physicians staff some consult services, hospitalists with less formal addiction credentials staff others.

Broadly, hospital-based addictions care cannot depend solely on consult services. Just as not all hospitals have cardiology consult services, not all hospitals will have addiction consult services. As such, hospitalists can play an even greater role by implementing order sets and guidelines, supporting partnerships with community SUD treatment, and independently initiating evidence-based medications.

Pervasive individual and structural stigmas¹² are perhaps the most critical barriers to incorporating addiction medicine into routine hospital practice, and they are both cause and consequence of our system failures. Most medical schools and residencies lack SUD training, which means that the understanding of addiction as a moral deficiency or lack of willpower may remain unchallenged. Stigma surrounding SUDs contributes to hospitalists’ and hospital leaders’ aversion to treating patients with SUD, and to fears that providing quality SUD care will attract patients suffering from these conditions.

Recent national efforts have focused on the problem of opioid overprescribing. Without an equal emphasis on treatment, this focus can lead to undertreatment of pain and/or opioid use disorder in hospitalized patients, particularly since most hospitalists have little to no training in diagnosing SUD, prescribing life-saving medications for opioid use disorder, or managing acute pain in patients with SUD. The focus on overprescribing also diverts attention away from trends involving stimulants,² fentanyl contamination of the drug supply,¹³ and alcohol, all of which have important implications for the care of hospitalized adults.

Hospital policies are often not grounded in evidence (eg, recommending clonidine for first-line treatment of opioid withdrawal and not buprenorphine/methadone), and there are widespread misconceptions about perceived legal barriers to treating opioid use disorder in the hospital, which is both safe and legal.¹⁰ People with SUD may be unjustly viewed through a criminal justice lens. Policies focused on controlling visitors and conducting room searches disproportionately burden people with SUD, which may create further harms through reinforcing negative provider cognitive biases about SUDs. Finally, hospitals may lack inpatient social work and pharmacy supports, and they rarely have pathways to connect people to SUD care after discharge.

Funding remains a widespread challenge. While some hospital administrators support addiction medicine services because of the pressing medical need and public health crisis, most services depend on billing or demonstrated savings through reduced hospital days or readmissions.

Individual hospitalists, hospitalist leaders, and hospitalist organizations can engage by improving individual practice, driving systems change, and through advocacy and policy change (Table).

Individual Hospitalists

Providing basic addiction medicine care should be a core competency for all hospitalists, just as every hospitalist can initiate a goals-of-care conversation or prescribe insulin. For opioid use disorder, hospitalists should treat withdrawal and offer treatment initiation with opioid agonist therapy (ie, methadone, buprenorphine), which reduces mortality by over half. Commonly, hospitalized patients are subjected to harmful, nonevidence-based treatments, such as mandated rapid methadone tapers,²⁵ which can lead to undertreated withdrawal, increased pain, and opioid cravings. This increases patients’ risk for overdose after discharge and precludes them from receiving life-saving, evidence-based methadone maintenance, or buprenorphine treatment. Though widely misunderstood, prescribing methadone in the hospital is legal, and providers need no special waiver to prescribe buprenorphine during admission. Current laws require that hospitalists have a waiver to prescribe buprenorphine at discharge and prohibit hospitalists (or anyone outside of an opioid treatment program) from prescribing methadone for the treatment of opioid use disorder at discharge. Further, hospitalists should offer medication for alcohol use disorder (eg, naltrexone) and be good stewards of opioids during hospitalization, avoiding intravenous opioids where appropriate and curbing excessive prescribing at discharge. Given high rates of overdose and fentanyl contamination of stimulants, opioids, and benzodiazepines, hospitalists should prescribe naloxone at discharge to every patient with SUD, on chronic opioids, or who uses any nonmedical substances.

Resources exist for individual hospitalists seeking mentorship or additional training (Table). Though not necessary for in-hospital prescribing, hospitalists can obtain a waiver to prescribe buprenorphine at discharge (commonly called the X-waiver). To qualify, physicians must complete eight hours of accredited training (online and/or in-person), after which they must request a waiver from the Drug Enforcement Administration. Advanced-practice practitioners must complete 24 hours of training. Many have argued that policymakers should end this waiver requirement.²⁶ While we support efforts to “X the X” and urgently expand treatment access, additional training can enrich providers’ knowledge and confidence to prescribe buprenorphine, and is a relatively simple way that all hospitalists could act. Finally, by treating addiction and modeling patient-centered addictions care, hospitalists can legitimize and destigmatize the disease of addiction,⁸ and have the potential to mentor and train students, residents, nurses, and other staff.²⁷

Hospitalist Leaders

As leaders, hospitalists can play a key role in promoting hospital-based addictions care and tailoring solutions to meet local needs. Leaders can promote a cultural shift away from stigma, and promote evidence-based, life-saving care. Hospitalist leaders could require all hospitalists to obtain buprenorphine waivers. Leaders could initiate quality improvement projects related to SUD service delivery, develop policies that support inpatient SUD treatment, develop order sets for medication initiation, engage community substance use treatment partners, build pathways to timely addiction care after discharge, and champion development of addiction medicine consult services.

Hospitalist leaders can reference open-source guidelines, order sets, assessment and treatment tools, patient materials, pharmacy and therapeutics committee materials, and other resources for implementing services for hospitalized patients with SUD (Table).^21,22 Hospitalist leaders who understand financial and quality drivers can also champion the business and quality case for hospital-based addictions care, and help pursue local and national funding opportunities.

Hospitalist Organizations

Hospitalist societies could provide training at regional and national conferences to upskill hospitalists to care for people with SUD; support addiction medicine interest groups; and partner with addiction medicine societies, harm reduction organizations, and organizations focused on trauma-informed care. They could endorse practice guidelines and position statements describing the crucial role of hospitalists in addressing the overdose crisis and offering medication for addiction (Table). Hospitalist organizations can engage national and state hospital associations, lobby medical specialties to include addiction medicine competencies in board certification requirements, and advocate with governmental leaders to reduce barriers that restrict treatment access such as the X-waiver.

Regardless of whether a hospitalist is serving as an individual provider, a hospitalist leader, or as part of a hospitalist organization, hospitalists can take critical steps to advance the care of people with SUD. These steps shift the culture of hospitals from one where patients are afraid to discuss their substance use, to one that creates space for connection, treatment engagement, and healing. By starting medications, utilizing widely accessible resources, and collaborating with community treatment and harm reduction organizations, each one of us can play a part in addressing the epidemic.

Acknowledgments

The authors thank Alisa Patten for help preparing this manuscript. Dr. Englander would like to thank Dr. David Bangsberg and Dr. Christina Nicolaidis for their mentorship.

I stand in the hospital room of a little girl who was shot in her own home just two weeks ago. She was drawing in her sketchbook when a group of teenagers drove by her apartment and took aim. She was shot twice in the chest. Her life and her health will forever be altered. I am not part of her care team, but I am there because just hours after their arrival to the hospital her mother declared that she was going to do something, that gun violence must be stopped. She wants to speak out and she wants to give her daughter a voice. She does not want this to happen to other little girls. My colleagues know that I can help this woman by elevating her voice, by telling her daughter’s story. I have found a passion in gun violence prevention advocacy and I fight every day for little girls like this.

For almost 10 years, I studied asthma. I presented lectures. I conducted research. I published papers. It was my thing. In fact, it still is my thing. But one day shortly after the shooting at Marjory Stoneman Douglas High School in Parkland, Florida, I was dropping my oldest daughter off at Kindergarten and for the first time, I saw an armed police officer patrolling the drop-off line. It hit me like a ton of bricks. I went home and called my Senators and Representatives. As I was talking to an aide about evidence-based gun safety legislation, I lost it. I started crying. I finished the call and just sat there. I was momentarily frozen, uncertain of what to do next yet compelled to take action. I decided to attend a meeting of a local gun violence prevention group. Maybe this action of going to one meeting would quell the anxiety and fear that was building inside of me. I found my local Moms Demand Action chapter and I went. About halfway through the meeting, the chapter leader began describing their gun safety campaign, Be SMART for kids, and mentioned that they had been trying to make connections with the Children’s Hospital. That is the moment. That is when it clicked. I have a voice that this movement needs. I can help them. And I did.

Gun violence is the second leading cause of death in children.¹ Gun violence is a public health epidemic. Every day in America, approximately 100 people are shot and killed.² The rate of firearm deaths among children and teens in the United States is 36.5 times higher than that of 12 other high-income countries.¹ We know that states with stricter gun laws have lower rates of child firearm mortality.³ We also know that safe gun storage practices (storing guns locked, unloaded, and separate from ammunition) reduce the risk of suicide and firearm injuries,⁴ yet 4.6 million American children live in a home with a loaded, unlocked firearm.⁵ Promoting safe gun storage practices and advocating for common sense gun safety legislation are two effective ways to address this crisis.

Gun violence prevention is my passion, but it might not be yours. Regardless of your passion, the blueprint for becoming a physician advocate is the same.

Advocacy, in its most distilled form, is speaking out for something you believe in, often for someone who cannot speak out for themselves. This is at the core of what we, as healthcare providers, do every day. We help people through some of the hardest moments of their lives, when they are sick and vulnerable. Every day, we are faced with problems that need to be solved. Our experience at the bedside helps us understand how policies affect real people. We understand evidence, data, and science. We recognize that anecdotes are powerful but if not backed up with data will be unlikely to lead to meaningful change. Perhaps most importantly, as professional members of the community, we have agency. We can use our voice and our privilege as physicians to elevate the voices of others.

As you go through medical training, you may not even realize that what you are doing on a daily basis is advocacy. But there comes a moment when you realize that the problem is bigger than the individual patient in front of you. There are systems that are broken that, if fixed, could improve the health of patients everywhere and save lives. To create change on a population level, the status quo will need to be challenged and systems may need to be disrupted.

Hospitalists are particularly well positioned to be advocates because we interact with virtually all aspects of the healthcare system either directly or indirectly. We care for patients with a myriad of disease processes and medical needs using varying levels of resources and social support systems. We often see patients in their most dire moments and, unlike outpatient physicians, we have the luxury of time. Hospitalized patients are a captive audience. We have time to educate, assess what patients need, and connect patients with community resources.

Find your passion. Often, your passion will find you. When it does, listen to it. Initially, most of your advocacy will be done on your own time. If you are not passionate about your cause, you will struggle and you will be less likely to be an effective advocate. Keep in mind that sometimes the deeper you dig into an issue, the bigger problems you find and, as a result, your passion can grow.

Do your research. Read the literature. Do you really understand the issue? Identify local and national experts, read their work, and follow their careers. You do not need an advanced degree. Your experience as a physician, willingness to learn, and your voice are all you need.

Start small. Do something small every day. Read an article. Make a new contact. Talk to a colleague. Be thoughtful in your approach. Is this a problem that community advocacy can solve? Will legislation be an effective way to achieve my goal? Would state or federal legislation be more appropriate? In most cases, a combination of community advocacy and legislative advocacy is necessary.

Partner with community organizations. Find local organizations that have existing infrastructure and are engaged on the issue and create partnerships. Community organizations are fighting every day and are waiting for a powerful authoritative voice like yours. They want your voice and you need their support.

Find your allies and your challengers. Identify allies in your community, your institution, your field, and in government. Anticipate potential challengers. When you encounter them, work diligently to find common ground and be respectful. If you only talk to people who agree with you, you will not make progress. Tread carefully when necessary. Develop a thick skin. Read people and try to figure out what it is that they want, what is motivating their position. Make your first ask small and as noncontroversial as possible. Stick to the facts. If you keep your patients at the heart of what you are doing, it is hard to go wrong.

Stay focused and disciplined, but do not quiet the anger and frustration that you feel. That is your fuel. Build momentum and build your team. Passion is contagious; when people see that you are making progress, they will want to join you. Together, you can create a dialog that will change minds.

Align advocacy with your other work. Ideally, this work will not be done in isolation from your other professional duties. Advocacy initiatives make excellent quality improvement projects. When you identify holes in the evidence that could potentially inform the policy debate, apply health services research methods and publish. This approach builds the evidence base to affect change and contributes to your professional development. Consider developing an advocacy curriculum for trainees. Identify trainees interested in advocacy and mentor them. Look for opportunities to speak and write on the topic. Use your unique skillset to further your cause.

Work with your employer. Find common ground. Even if they fundamentally disagree with your point of view, you can still speak out as a private citizen. Recognize the difference between speaking as a physician and speaking as an employee of a specific institution. Unless you have explicit permission, you are speaking for yourself, not your institution. Do not be afraid to push leaders at your institution. Help them see why it is important for you to speak up on a particular issue. If your professional organization has a statement on the issue, use it to support your position.

Leverage social media. Social media is a powerful method to amplify your voice. Consider the impact of the #thisisourlane movement. It will connect you with people, across the world, who share similar passions. It will help you identify local allies. It will open opportunities for speaking engagements and publications. It can be a great way to bring positive attention to your institution. It will take time to find your voice. Try to use consistent messaging. Keep it professional. Tag people who you want to see the great work you are doing. It only takes one retweet by someone with hundreds of thousands of followers to get your message in the feed of exponentially more viewers. Tag your institution when you want them to know what you are up to or when you are doing something that you think they should be proud of. Tag the professional organizations that would be interested in your work. Tag community leaders. This can be a great way to elevate their voice with your platform. Include an “opinions my own” statement in your social media profiles. Beware of disinformation. Read articles before retweeting. Ignore the trolls. I repeat, ignore the trolls.

I did not start my career with a focus on advocacy and in becoming an advocate, I have not given up my previous focus on asthma research. I did not get an advanced degree or specialized training in advocacy. I let my passion drive me. I am now an active member and leader in our Moms Demand Action chapter. The safe storage campaign in our resident clinic has had significant success. We increased the frequency of discussion of gun safety during well-child visits from 2% to 50% and shared this success at local and national scientific meetings. We have worked with our local media to spread awareness about safe gun storage. We have spent time at the state capital to discuss child access prevention laws with legislators. We have collaborated with community leaders and elected officials for gun violence awareness events. We earned support from leaders at our institution. If you walk through our hospital units, clinics, resident areas, and faculty offices, you will see evidence of our success. Physicians and nurses are still wearing their ribbons from the Wear Orange day on their name badges. “We Can End Gun Violence” signs are hanging on faculty members’ doors. Thanks to local police departments, the clinic has a constant supply of gun locks that are provided to families free of charge. Our residents proudly walk the halls with Be SMART buttons on their badges. These physical reminders of our progress are incredibly motivating as we continue this work. However, it is the quiet moments alone with children and parents who are suffering because of the epidemic of gun violence that really move me. I will not give up this fight until children in our communities are safe.

Acknowledgments

Dr. Andrews wishes to thank Dr. Kelsey Gastineau for her efforts to increase the frequency of gun safety discussions in our Pediatric Primary Care clinic and for her support in all of this work.

I stand in the hospital room of a little girl who was shot in her own home just two weeks ago. She was drawing in her sketchbook when a group of teenagers drove by her apartment and took aim. She was shot twice in the chest. Her life and her health will forever be altered. I am not part of her care team, but I am there because just hours after their arrival to the hospital her mother declared that she was going to do something, that gun violence must be stopped. She wants to speak out and she wants to give her daughter a voice. She does not want this to happen to other little girls. My colleagues know that I can help this woman by elevating her voice, by telling her daughter’s story. I have found a passion in gun violence prevention advocacy and I fight every day for little girls like this.

For almost 10 years, I studied asthma. I presented lectures. I conducted research. I published papers. It was my thing. In fact, it still is my thing. But one day shortly after the shooting at Marjory Stoneman Douglas High School in Parkland, Florida, I was dropping my oldest daughter off at Kindergarten and for the first time, I saw an armed police officer patrolling the drop-off line. It hit me like a ton of bricks. I went home and called my Senators and Representatives. As I was talking to an aide about evidence-based gun safety legislation, I lost it. I started crying. I finished the call and just sat there. I was momentarily frozen, uncertain of what to do next yet compelled to take action. I decided to attend a meeting of a local gun violence prevention group. Maybe this action of going to one meeting would quell the anxiety and fear that was building inside of me. I found my local Moms Demand Action chapter and I went. About halfway through the meeting, the chapter leader began describing their gun safety campaign, Be SMART for kids, and mentioned that they had been trying to make connections with the Children’s Hospital. That is the moment. That is when it clicked. I have a voice that this movement needs. I can help them. And I did.

Gun violence is the second leading cause of death in children.¹ Gun violence is a public health epidemic. Every day in America, approximately 100 people are shot and killed.² The rate of firearm deaths among children and teens in the United States is 36.5 times higher than that of 12 other high-income countries.¹ We know that states with stricter gun laws have lower rates of child firearm mortality.³ We also know that safe gun storage practices (storing guns locked, unloaded, and separate from ammunition) reduce the risk of suicide and firearm injuries,⁴ yet 4.6 million American children live in a home with a loaded, unlocked firearm.⁵ Promoting safe gun storage practices and advocating for common sense gun safety legislation are two effective ways to address this crisis.

Gun violence prevention is my passion, but it might not be yours. Regardless of your passion, the blueprint for becoming a physician advocate is the same.

Advocacy, in its most distilled form, is speaking out for something you believe in, often for someone who cannot speak out for themselves. This is at the core of what we, as healthcare providers, do every day. We help people through some of the hardest moments of their lives, when they are sick and vulnerable. Every day, we are faced with problems that need to be solved. Our experience at the bedside helps us understand how policies affect real people. We understand evidence, data, and science. We recognize that anecdotes are powerful but if not backed up with data will be unlikely to lead to meaningful change. Perhaps most importantly, as professional members of the community, we have agency. We can use our voice and our privilege as physicians to elevate the voices of others.

As you go through medical training, you may not even realize that what you are doing on a daily basis is advocacy. But there comes a moment when you realize that the problem is bigger than the individual patient in front of you. There are systems that are broken that, if fixed, could improve the health of patients everywhere and save lives. To create change on a population level, the status quo will need to be challenged and systems may need to be disrupted.

Hospitalists are particularly well positioned to be advocates because we interact with virtually all aspects of the healthcare system either directly or indirectly. We care for patients with a myriad of disease processes and medical needs using varying levels of resources and social support systems. We often see patients in their most dire moments and, unlike outpatient physicians, we have the luxury of time. Hospitalized patients are a captive audience. We have time to educate, assess what patients need, and connect patients with community resources.

Find your passion. Often, your passion will find you. When it does, listen to it. Initially, most of your advocacy will be done on your own time. If you are not passionate about your cause, you will struggle and you will be less likely to be an effective advocate. Keep in mind that sometimes the deeper you dig into an issue, the bigger problems you find and, as a result, your passion can grow.

Do your research. Read the literature. Do you really understand the issue? Identify local and national experts, read their work, and follow their careers. You do not need an advanced degree. Your experience as a physician, willingness to learn, and your voice are all you need.

Start small. Do something small every day. Read an article. Make a new contact. Talk to a colleague. Be thoughtful in your approach. Is this a problem that community advocacy can solve? Will legislation be an effective way to achieve my goal? Would state or federal legislation be more appropriate? In most cases, a combination of community advocacy and legislative advocacy is necessary.

Partner with community organizations. Find local organizations that have existing infrastructure and are engaged on the issue and create partnerships. Community organizations are fighting every day and are waiting for a powerful authoritative voice like yours. They want your voice and you need their support.

Find your allies and your challengers. Identify allies in your community, your institution, your field, and in government. Anticipate potential challengers. When you encounter them, work diligently to find common ground and be respectful. If you only talk to people who agree with you, you will not make progress. Tread carefully when necessary. Develop a thick skin. Read people and try to figure out what it is that they want, what is motivating their position. Make your first ask small and as noncontroversial as possible. Stick to the facts. If you keep your patients at the heart of what you are doing, it is hard to go wrong.

Stay focused and disciplined, but do not quiet the anger and frustration that you feel. That is your fuel. Build momentum and build your team. Passion is contagious; when people see that you are making progress, they will want to join you. Together, you can create a dialog that will change minds.

Align advocacy with your other work. Ideally, this work will not be done in isolation from your other professional duties. Advocacy initiatives make excellent quality improvement projects. When you identify holes in the evidence that could potentially inform the policy debate, apply health services research methods and publish. This approach builds the evidence base to affect change and contributes to your professional development. Consider developing an advocacy curriculum for trainees. Identify trainees interested in advocacy and mentor them. Look for opportunities to speak and write on the topic. Use your unique skillset to further your cause.

Work with your employer. Find common ground. Even if they fundamentally disagree with your point of view, you can still speak out as a private citizen. Recognize the difference between speaking as a physician and speaking as an employee of a specific institution. Unless you have explicit permission, you are speaking for yourself, not your institution. Do not be afraid to push leaders at your institution. Help them see why it is important for you to speak up on a particular issue. If your professional organization has a statement on the issue, use it to support your position.

Leverage social media. Social media is a powerful method to amplify your voice. Consider the impact of the #thisisourlane movement. It will connect you with people, across the world, who share similar passions. It will help you identify local allies. It will open opportunities for speaking engagements and publications. It can be a great way to bring positive attention to your institution. It will take time to find your voice. Try to use consistent messaging. Keep it professional. Tag people who you want to see the great work you are doing. It only takes one retweet by someone with hundreds of thousands of followers to get your message in the feed of exponentially more viewers. Tag your institution when you want them to know what you are up to or when you are doing something that you think they should be proud of. Tag the professional organizations that would be interested in your work. Tag community leaders. This can be a great way to elevate their voice with your platform. Include an “opinions my own” statement in your social media profiles. Beware of disinformation. Read articles before retweeting. Ignore the trolls. I repeat, ignore the trolls.

I did not start my career with a focus on advocacy and in becoming an advocate, I have not given up my previous focus on asthma research. I did not get an advanced degree or specialized training in advocacy. I let my passion drive me. I am now an active member and leader in our Moms Demand Action chapter. The safe storage campaign in our resident clinic has had significant success. We increased the frequency of discussion of gun safety during well-child visits from 2% to 50% and shared this success at local and national scientific meetings. We have worked with our local media to spread awareness about safe gun storage. We have spent time at the state capital to discuss child access prevention laws with legislators. We have collaborated with community leaders and elected officials for gun violence awareness events. We earned support from leaders at our institution. If you walk through our hospital units, clinics, resident areas, and faculty offices, you will see evidence of our success. Physicians and nurses are still wearing their ribbons from the Wear Orange day on their name badges. “We Can End Gun Violence” signs are hanging on faculty members’ doors. Thanks to local police departments, the clinic has a constant supply of gun locks that are provided to families free of charge. Our residents proudly walk the halls with Be SMART buttons on their badges. These physical reminders of our progress are incredibly motivating as we continue this work. However, it is the quiet moments alone with children and parents who are suffering because of the epidemic of gun violence that really move me. I will not give up this fight until children in our communities are safe.

Acknowledgments

Dr. Andrews wishes to thank Dr. Kelsey Gastineau for her efforts to increase the frequency of gun safety discussions in our Pediatric Primary Care clinic and for her support in all of this work.

I stand in the hospital room of a little girl who was shot in her own home just two weeks ago. She was drawing in her sketchbook when a group of teenagers drove by her apartment and took aim. She was shot twice in the chest. Her life and her health will forever be altered. I am not part of her care team, but I am there because just hours after their arrival to the hospital her mother declared that she was going to do something, that gun violence must be stopped. She wants to speak out and she wants to give her daughter a voice. She does not want this to happen to other little girls. My colleagues know that I can help this woman by elevating her voice, by telling her daughter’s story. I have found a passion in gun violence prevention advocacy and I fight every day for little girls like this.

For almost 10 years, I studied asthma. I presented lectures. I conducted research. I published papers. It was my thing. In fact, it still is my thing. But one day shortly after the shooting at Marjory Stoneman Douglas High School in Parkland, Florida, I was dropping my oldest daughter off at Kindergarten and for the first time, I saw an armed police officer patrolling the drop-off line. It hit me like a ton of bricks. I went home and called my Senators and Representatives. As I was talking to an aide about evidence-based gun safety legislation, I lost it. I started crying. I finished the call and just sat there. I was momentarily frozen, uncertain of what to do next yet compelled to take action. I decided to attend a meeting of a local gun violence prevention group. Maybe this action of going to one meeting would quell the anxiety and fear that was building inside of me. I found my local Moms Demand Action chapter and I went. About halfway through the meeting, the chapter leader began describing their gun safety campaign, Be SMART for kids, and mentioned that they had been trying to make connections with the Children’s Hospital. That is the moment. That is when it clicked. I have a voice that this movement needs. I can help them. And I did.

Gun violence is the second leading cause of death in children.¹ Gun violence is a public health epidemic. Every day in America, approximately 100 people are shot and killed.² The rate of firearm deaths among children and teens in the United States is 36.5 times higher than that of 12 other high-income countries.¹ We know that states with stricter gun laws have lower rates of child firearm mortality.³ We also know that safe gun storage practices (storing guns locked, unloaded, and separate from ammunition) reduce the risk of suicide and firearm injuries,⁴ yet 4.6 million American children live in a home with a loaded, unlocked firearm.⁵ Promoting safe gun storage practices and advocating for common sense gun safety legislation are two effective ways to address this crisis.

Gun violence prevention is my passion, but it might not be yours. Regardless of your passion, the blueprint for becoming a physician advocate is the same.

Advocacy, in its most distilled form, is speaking out for something you believe in, often for someone who cannot speak out for themselves. This is at the core of what we, as healthcare providers, do every day. We help people through some of the hardest moments of their lives, when they are sick and vulnerable. Every day, we are faced with problems that need to be solved. Our experience at the bedside helps us understand how policies affect real people. We understand evidence, data, and science. We recognize that anecdotes are powerful but if not backed up with data will be unlikely to lead to meaningful change. Perhaps most importantly, as professional members of the community, we have agency. We can use our voice and our privilege as physicians to elevate the voices of others.

As you go through medical training, you may not even realize that what you are doing on a daily basis is advocacy. But there comes a moment when you realize that the problem is bigger than the individual patient in front of you. There are systems that are broken that, if fixed, could improve the health of patients everywhere and save lives. To create change on a population level, the status quo will need to be challenged and systems may need to be disrupted.

Hospitalists are particularly well positioned to be advocates because we interact with virtually all aspects of the healthcare system either directly or indirectly. We care for patients with a myriad of disease processes and medical needs using varying levels of resources and social support systems. We often see patients in their most dire moments and, unlike outpatient physicians, we have the luxury of time. Hospitalized patients are a captive audience. We have time to educate, assess what patients need, and connect patients with community resources.

Find your passion. Often, your passion will find you. When it does, listen to it. Initially, most of your advocacy will be done on your own time. If you are not passionate about your cause, you will struggle and you will be less likely to be an effective advocate. Keep in mind that sometimes the deeper you dig into an issue, the bigger problems you find and, as a result, your passion can grow.

Do your research. Read the literature. Do you really understand the issue? Identify local and national experts, read their work, and follow their careers. You do not need an advanced degree. Your experience as a physician, willingness to learn, and your voice are all you need.

Start small. Do something small every day. Read an article. Make a new contact. Talk to a colleague. Be thoughtful in your approach. Is this a problem that community advocacy can solve? Will legislation be an effective way to achieve my goal? Would state or federal legislation be more appropriate? In most cases, a combination of community advocacy and legislative advocacy is necessary.

Partner with community organizations. Find local organizations that have existing infrastructure and are engaged on the issue and create partnerships. Community organizations are fighting every day and are waiting for a powerful authoritative voice like yours. They want your voice and you need their support.

Find your allies and your challengers. Identify allies in your community, your institution, your field, and in government. Anticipate potential challengers. When you encounter them, work diligently to find common ground and be respectful. If you only talk to people who agree with you, you will not make progress. Tread carefully when necessary. Develop a thick skin. Read people and try to figure out what it is that they want, what is motivating their position. Make your first ask small and as noncontroversial as possible. Stick to the facts. If you keep your patients at the heart of what you are doing, it is hard to go wrong.

Stay focused and disciplined, but do not quiet the anger and frustration that you feel. That is your fuel. Build momentum and build your team. Passion is contagious; when people see that you are making progress, they will want to join you. Together, you can create a dialog that will change minds.

Align advocacy with your other work. Ideally, this work will not be done in isolation from your other professional duties. Advocacy initiatives make excellent quality improvement projects. When you identify holes in the evidence that could potentially inform the policy debate, apply health services research methods and publish. This approach builds the evidence base to affect change and contributes to your professional development. Consider developing an advocacy curriculum for trainees. Identify trainees interested in advocacy and mentor them. Look for opportunities to speak and write on the topic. Use your unique skillset to further your cause.

Work with your employer. Find common ground. Even if they fundamentally disagree with your point of view, you can still speak out as a private citizen. Recognize the difference between speaking as a physician and speaking as an employee of a specific institution. Unless you have explicit permission, you are speaking for yourself, not your institution. Do not be afraid to push leaders at your institution. Help them see why it is important for you to speak up on a particular issue. If your professional organization has a statement on the issue, use it to support your position.

Leverage social media. Social media is a powerful method to amplify your voice. Consider the impact of the #thisisourlane movement. It will connect you with people, across the world, who share similar passions. It will help you identify local allies. It will open opportunities for speaking engagements and publications. It can be a great way to bring positive attention to your institution. It will take time to find your voice. Try to use consistent messaging. Keep it professional. Tag people who you want to see the great work you are doing. It only takes one retweet by someone with hundreds of thousands of followers to get your message in the feed of exponentially more viewers. Tag your institution when you want them to know what you are up to or when you are doing something that you think they should be proud of. Tag the professional organizations that would be interested in your work. Tag community leaders. This can be a great way to elevate their voice with your platform. Include an “opinions my own” statement in your social media profiles. Beware of disinformation. Read articles before retweeting. Ignore the trolls. I repeat, ignore the trolls.

I did not start my career with a focus on advocacy and in becoming an advocate, I have not given up my previous focus on asthma research. I did not get an advanced degree or specialized training in advocacy. I let my passion drive me. I am now an active member and leader in our Moms Demand Action chapter. The safe storage campaign in our resident clinic has had significant success. We increased the frequency of discussion of gun safety during well-child visits from 2% to 50% and shared this success at local and national scientific meetings. We have worked with our local media to spread awareness about safe gun storage. We have spent time at the state capital to discuss child access prevention laws with legislators. We have collaborated with community leaders and elected officials for gun violence awareness events. We earned support from leaders at our institution. If you walk through our hospital units, clinics, resident areas, and faculty offices, you will see evidence of our success. Physicians and nurses are still wearing their ribbons from the Wear Orange day on their name badges. “We Can End Gun Violence” signs are hanging on faculty members’ doors. Thanks to local police departments, the clinic has a constant supply of gun locks that are provided to families free of charge. Our residents proudly walk the halls with Be SMART buttons on their badges. These physical reminders of our progress are incredibly motivating as we continue this work. However, it is the quiet moments alone with children and parents who are suffering because of the epidemic of gun violence that really move me. I will not give up this fight until children in our communities are safe.

Acknowledgments

Dr. Andrews wishes to thank Dr. Kelsey Gastineau for her efforts to increase the frequency of gun safety discussions in our Pediatric Primary Care clinic and for her support in all of this work.

In 2016, Pediatric Hospital Medicine (PHM) was recognized as a subspecialty under the American Board of Pediatrics (ABP), one of 24 certifying boards of the American Board of Medical Specialties. As with all new ABP subspecialty certification processes, a “practice pathway” with specific eligibility criteria allows individuals with expertise and sufficient practice experience within the discipline to take the certification examination. For PHM, certification via the practice pathway is permissible for the 2019, 2021, and 2023 certifying examinations.¹ In this perspective, we provide an illustration of ABP leadership and the PHM community partnering to mitigate unintentional gender bias that surfaced after the practice pathway eligibility criteria were implemented. We also provide recommendations to revise these criteria to eliminate future gender bias and promote equity in medicine.

In July 2019, individuals within the PHM community began to share stories of being denied eligibility to sit for the 2019 exam.² Some of the reported denials were due to an eligibility criterion related to “practice interruptions”, which stated that practice interruptions cannot exceed three months in the preceding four years or six months in the preceding five years. Notably, some women reported that their applications were denied because of practice interruptions due to maternity leave. These stories raised significant concerns of gender bias in the board certification process and sparked collective action to revise the board certification eligibility criteria. A petition was circulated within the PHM community and received 1,479 signatures in two weeks.

Given the magnitude of concern, leaders within the PHM community, with support from the American Academy of Pediatrics, collaboratively engaged with the ABP and members of the ABP PHM subboard to improve the transparency and equity of the eligibility process. As a result of this activism and effective dialogue, the ABP revised the PHM board certification eligibility criteria and removed the practice interruption criterion.¹ Through this unique experience of advocacy and partnership in medicine, the PHM community and ABP were able to work together to mitigate unintentional gender bias in the board certification process. However, this collaboration must continue as we believe the revised criteria remain unintentionally biased against women.

Gender bias is defined as the unfair difference in the way men and women are treated.³ Maternal bias is further characterized as bias experienced by mothers related to motherhood, often involving discrimination based on pregnancy, maternity leave, or breastfeeding. Both are common in medicine. Two-thirds of physician mothers report experiencing gender bias and more than a third experience maternal bias.⁴ This bias may be explicit, or intentional, but often the bias is unintentional. This bias can occur even with equal representation of women and men on committees determining eligibility, and even when the committee believes it is not biased.⁵ Furthermore, gender or maternal bias negatively affects individuals in medicine in regards to future employment, career advancement, and compensation.^6-11

Given these implications, we celebrate the removal of the practice interruptions criterion as it was unintentionally biased against women. Eligibility criteria that considered practice interruptions would have disproportionately affected women due to leaves related to pregnancy and due to discrepancies in the length of parental leave for mothers versus fathers. Though the ABP’s initial review of cases of denial did not demonstrate a significant difference in the proportion of men and women who were denied, these data may be misleading. Potential reasons why the ABP did not find significant differences in denial rates between women and men include: (1) some women who had recent maternity leaves chose not to apply because of concerns they may be denied; or (2) some women did not disclose maternity leaves on their application because they did not interpret maternity leave to be a practice interruption. This “self-censoring” may have resulted in incomplete data, making it difficult to fully understand the differential impact of this criterion on women versus men. Therefore, it is essential that we as a profession continue to identify any areas where gender bias exists in determining eligibility for certification, employment, or career advancement within medicine and eliminate it.

Despite the improvements made in the revised criteria, further revision is necessary to remove the criterion related to the “start date”, which will differentially affect women. This criterion states that an individual must have started their PHM practice on or before July of the first year of a four-year look-back period (eg, July 2015 for the 2019 cycle). We present three theoretical cases to illustrate gender bias with respect to this criterion (Table). Even though Applicants #2 and #3 accrue far more than the minimum number of hours in their first year—and more hours overall than Applicant #1—both of these women will remain ineligible under the revised criteria. While Applicant #2 could be eligible for the 2021 or 2023 cycle, Applicant #3, who is new to PHM practice in 2019 as a residency graduate, will not be eligible at all under the practice pathway due to delayed graduation from residency.

Disclosures

The authors have nothing to disclose.

In 2016, Pediatric Hospital Medicine (PHM) was recognized as a subspecialty under the American Board of Pediatrics (ABP), one of 24 certifying boards of the American Board of Medical Specialties. As with all new ABP subspecialty certification processes, a “practice pathway” with specific eligibility criteria allows individuals with expertise and sufficient practice experience within the discipline to take the certification examination. For PHM, certification via the practice pathway is permissible for the 2019, 2021, and 2023 certifying examinations.¹ In this perspective, we provide an illustration of ABP leadership and the PHM community partnering to mitigate unintentional gender bias that surfaced after the practice pathway eligibility criteria were implemented. We also provide recommendations to revise these criteria to eliminate future gender bias and promote equity in medicine.

In July 2019, individuals within the PHM community began to share stories of being denied eligibility to sit for the 2019 exam.² Some of the reported denials were due to an eligibility criterion related to “practice interruptions”, which stated that practice interruptions cannot exceed three months in the preceding four years or six months in the preceding five years. Notably, some women reported that their applications were denied because of practice interruptions due to maternity leave. These stories raised significant concerns of gender bias in the board certification process and sparked collective action to revise the board certification eligibility criteria. A petition was circulated within the PHM community and received 1,479 signatures in two weeks.

Given the magnitude of concern, leaders within the PHM community, with support from the American Academy of Pediatrics, collaboratively engaged with the ABP and members of the ABP PHM subboard to improve the transparency and equity of the eligibility process. As a result of this activism and effective dialogue, the ABP revised the PHM board certification eligibility criteria and removed the practice interruption criterion.¹ Through this unique experience of advocacy and partnership in medicine, the PHM community and ABP were able to work together to mitigate unintentional gender bias in the board certification process. However, this collaboration must continue as we believe the revised criteria remain unintentionally biased against women.

Gender bias is defined as the unfair difference in the way men and women are treated.³ Maternal bias is further characterized as bias experienced by mothers related to motherhood, often involving discrimination based on pregnancy, maternity leave, or breastfeeding. Both are common in medicine. Two-thirds of physician mothers report experiencing gender bias and more than a third experience maternal bias.⁴ This bias may be explicit, or intentional, but often the bias is unintentional. This bias can occur even with equal representation of women and men on committees determining eligibility, and even when the committee believes it is not biased.⁵ Furthermore, gender or maternal bias negatively affects individuals in medicine in regards to future employment, career advancement, and compensation.^6-11

Given these implications, we celebrate the removal of the practice interruptions criterion as it was unintentionally biased against women. Eligibility criteria that considered practice interruptions would have disproportionately affected women due to leaves related to pregnancy and due to discrepancies in the length of parental leave for mothers versus fathers. Though the ABP’s initial review of cases of denial did not demonstrate a significant difference in the proportion of men and women who were denied, these data may be misleading. Potential reasons why the ABP did not find significant differences in denial rates between women and men include: (1) some women who had recent maternity leaves chose not to apply because of concerns they may be denied; or (2) some women did not disclose maternity leaves on their application because they did not interpret maternity leave to be a practice interruption. This “self-censoring” may have resulted in incomplete data, making it difficult to fully understand the differential impact of this criterion on women versus men. Therefore, it is essential that we as a profession continue to identify any areas where gender bias exists in determining eligibility for certification, employment, or career advancement within medicine and eliminate it.

Despite the improvements made in the revised criteria, further revision is necessary to remove the criterion related to the “start date”, which will differentially affect women. This criterion states that an individual must have started their PHM practice on or before July of the first year of a four-year look-back period (eg, July 2015 for the 2019 cycle). We present three theoretical cases to illustrate gender bias with respect to this criterion (Table). Even though Applicants #2 and #3 accrue far more than the minimum number of hours in their first year—and more hours overall than Applicant #1—both of these women will remain ineligible under the revised criteria. While Applicant #2 could be eligible for the 2021 or 2023 cycle, Applicant #3, who is new to PHM practice in 2019 as a residency graduate, will not be eligible at all under the practice pathway due to delayed graduation from residency.

Disclosures

The authors have nothing to disclose.

In 2016, Pediatric Hospital Medicine (PHM) was recognized as a subspecialty under the American Board of Pediatrics (ABP), one of 24 certifying boards of the American Board of Medical Specialties. As with all new ABP subspecialty certification processes, a “practice pathway” with specific eligibility criteria allows individuals with expertise and sufficient practice experience within the discipline to take the certification examination. For PHM, certification via the practice pathway is permissible for the 2019, 2021, and 2023 certifying examinations.¹ In this perspective, we provide an illustration of ABP leadership and the PHM community partnering to mitigate unintentional gender bias that surfaced after the practice pathway eligibility criteria were implemented. We also provide recommendations to revise these criteria to eliminate future gender bias and promote equity in medicine.

In July 2019, individuals within the PHM community began to share stories of being denied eligibility to sit for the 2019 exam.² Some of the reported denials were due to an eligibility criterion related to “practice interruptions”, which stated that practice interruptions cannot exceed three months in the preceding four years or six months in the preceding five years. Notably, some women reported that their applications were denied because of practice interruptions due to maternity leave. These stories raised significant concerns of gender bias in the board certification process and sparked collective action to revise the board certification eligibility criteria. A petition was circulated within the PHM community and received 1,479 signatures in two weeks.

Given the magnitude of concern, leaders within the PHM community, with support from the American Academy of Pediatrics, collaboratively engaged with the ABP and members of the ABP PHM subboard to improve the transparency and equity of the eligibility process. As a result of this activism and effective dialogue, the ABP revised the PHM board certification eligibility criteria and removed the practice interruption criterion.¹ Through this unique experience of advocacy and partnership in medicine, the PHM community and ABP were able to work together to mitigate unintentional gender bias in the board certification process. However, this collaboration must continue as we believe the revised criteria remain unintentionally biased against women.

Gender bias is defined as the unfair difference in the way men and women are treated.³ Maternal bias is further characterized as bias experienced by mothers related to motherhood, often involving discrimination based on pregnancy, maternity leave, or breastfeeding. Both are common in medicine. Two-thirds of physician mothers report experiencing gender bias and more than a third experience maternal bias.⁴ This bias may be explicit, or intentional, but often the bias is unintentional. This bias can occur even with equal representation of women and men on committees determining eligibility, and even when the committee believes it is not biased.⁵ Furthermore, gender or maternal bias negatively affects individuals in medicine in regards to future employment, career advancement, and compensation.^6-11

Given these implications, we celebrate the removal of the practice interruptions criterion as it was unintentionally biased against women. Eligibility criteria that considered practice interruptions would have disproportionately affected women due to leaves related to pregnancy and due to discrepancies in the length of parental leave for mothers versus fathers. Though the ABP’s initial review of cases of denial did not demonstrate a significant difference in the proportion of men and women who were denied, these data may be misleading. Potential reasons why the ABP did not find significant differences in denial rates between women and men include: (1) some women who had recent maternity leaves chose not to apply because of concerns they may be denied; or (2) some women did not disclose maternity leaves on their application because they did not interpret maternity leave to be a practice interruption. This “self-censoring” may have resulted in incomplete data, making it difficult to fully understand the differential impact of this criterion on women versus men. Therefore, it is essential that we as a profession continue to identify any areas where gender bias exists in determining eligibility for certification, employment, or career advancement within medicine and eliminate it.

Despite the improvements made in the revised criteria, further revision is necessary to remove the criterion related to the “start date”, which will differentially affect women. This criterion states that an individual must have started their PHM practice on or before July of the first year of a four-year look-back period (eg, July 2015 for the 2019 cycle). We present three theoretical cases to illustrate gender bias with respect to this criterion (Table). Even though Applicants #2 and #3 accrue far more than the minimum number of hours in their first year—and more hours overall than Applicant #1—both of these women will remain ineligible under the revised criteria. While Applicant #2 could be eligible for the 2021 or 2023 cycle, Applicant #3, who is new to PHM practice in 2019 as a residency graduate, will not be eligible at all under the practice pathway due to delayed graduation from residency.

Disclosures

The authors have nothing to disclose.

N o matter the era, few aspects of residency are more defining or memorable than overnight call. Nights can be a time of growth and learning but also of fear and uncertainty, as residents take on the responsibility of managing sick patients on their own. One of us (ASD) started his residency in 1978 at the Massachusetts General Hospital in Boston; the other two (ST and BCY) started theirs in 2016 and 2017, respectively, at the University of Toronto. In this essay, we reflect on our experiences of night call separated by 40 years, highlighting what has changed and what has stayed the same.

At 6 pm, a calm overtook the hospital as the daytime staff emptied out of the building. The only remaining residents were those on call for the night. Each team had one resident and one medical student responsible for about 20 inpatients. Teams also admitted new patients from the emergency department (ED). Since there were three teams who rotated the admissions, we were able to spend a part of our night on the inpatient ward. Most of the new patients had been thoroughly evaluated by a medical resident in the ED before we saw them, giving us a head start on eliciting their stories, performing physical examinations, reviewing the laboratory workup, and generating plans to present to the attending physician (who was called “the visit”) the next morning at 10 am .

We carried one pager that was about 7 inches long and 2 inches wide clipped to the waist of our pants. It could only make a beep; we then had to call the page operator to find out who wanted us. However, the pages were relatively few. Nurses called only when a patient was unstable, and other residents called only when a new patient was ready in the emergency department. At 9 pm , the laboratory data for the day were delivered to the ward nursing stations on computer-generated paper. Our job was to separate the pages connected by serrated breaks, review the results, and then file the pages in the charts. The nurses were aware of this routine, so they saved their questions for our presence on the wards, reducing the need to page us. At 10 pm , residents from all services went to the cafeteria for the “10 o’clock meal” when the food was free.We learned early in the year to drop everything at 10 pm ; otherwise, we did not eat. The social aspect of the group meal was comforting, but compared with today, the group was much more homogeneous and therefore less interesting. There were several women medical residents (although almost none in surgery), but very few minorities, and no openly gay residents.

Gathering data about patients prior to the current hospitalization required reviewing the “old chart,” which had to be delivered from patient records but was generally available when the patient was still in the ED. It contained typed discharge summaries and progress notes often handwritten by coresidents whom we knew. The handwriting was often difficult to read, outpatient notes were not included, and information from other hospitals was absent—but despite these deficiencies, we somehow managed just fine.

The patients on the inpatient ward were mostly stable, but more importantly, we had very few medications and tests to order. I recall prescribing fewer than 20 drugs—furosemide, hydrochlorothiazide, penicillins, cephalosporins, gentamicin, isoniazid, lidocaine, nitroglycerin, aminophylline, alpha-methyldopa, clonidine, propranolol, digoxin, hydralazine, indomethacin, steroids, and morphine. Orders for tests and imaging had to be physically written in the chart and could not be inputted remotely, which was a nuisance when we were away from the ward. However, we rarely ordered any imaging beyond plain radiographs at night. We did draw arterial blood gases and venous blood, administer oxygen, insert intravenous and central lines, take electrocardiograms, and perform urinalyses by microscopy. We did all these tasks ourselves for patients on the “ward service” (as opposed to the “private service”, which had to do with the type of insurance the patients possessed). As a result, we became experts in both blood drawing and intravenous line insertion—skills that might be less familiar to today’s residents.

Of course, patients did get acutely ill during the night. I recall intubating, cardioverting, performing phlebotomy to alleviate pulmonary edema, sending patients to surgery, and pronouncing death. Nevertheless, we often got sleep, and sometimes, several hours in a row. I had a rule; I always took a shower the next morning and put on clean clothes (we stayed until 5 pm , making the shifts 33.5 hours long). There was a camaraderie that existed between all of us at night. We were supportive, friendly, and knew each other by name, and more.

We were often frightened by the responsibility of managing sick patients alone. On particularly challenging nights, we would record our fears and feelings in a “night call diary” in one of the conference rooms—generally at 4 am . Some entries became legendary as people read and reread those months and years later. Mornings always brought a sense of relief and accomplishment, because when the sun came up, we knew that the other residents would not be far behind; when they arrived, we could tell our stories and get help.

There was definitely competitiveness to the work. Those who responded quickly to deteriorating patients were applauded; those who did not really know what to do were subtly disdained. However, over time, we all got the hang of it, and this led to a growing confidence that we were indeed doctors. The graded autonomy afforded by night call was a crucial part of that journey.

At 6 pm , the on-call residents assemble in the ED, where we would spend the remainder of the night and early morning admitting new patients to the hospital. A night team consists of a senior resident, three junior residents, and two medical students, with each resident being responsible for approximately 20 inpatients. Overnight coverage of the ward mostly occurs remotely; since the ED is often so busy, we address most of the issues through a computer or over the phone. Only in rare cases, such as when a patient is unstable or a death has occurred, do we deal with the matter in person.

To enable rapid remote responses, we each carry an assortment of devices on our waists or lanyards and in our pockets, such as a personal pager, ED consult pager, code blue pager, and hospital-issued smartphones capable of receiving pages, text messages, phone calls, and e-mails. Nurses, pharmacists, and other consultants communicate with us through all of these channels. Few of these interactions occur face-to-face. To our frustration, encounters with patients are frequently interrupted by a stream of beeps, rings, and vibrations—irrespective of whether we are having a difficult discussion about goals of care or performing a delicate procedure.

The ED contains a work space dedicated for residents to enter electronic orders, type notes, and review new admissions. Between consults, we try to discuss exciting cases and provide teaching to the medical students and interns, which we enjoy. Dinner is generally devoured while inputting orders. In exceptional circumstances, a brief reprieve from pages may allow the on-call team to share a meal. Depending on our role, sleep may be possible on certain nights but is never guaranteed. Moments spent with the on-call team—all of us learning, commiserating, and growing together—are some of the most memorable of residency, and many of us become close friends by the end of the rotation.

However, apart from these few familiar faces, we rarely get acquainted with the nurses or residents from other services. Many often refer to themselves by specialty rather than name and phone calls that begin with “Are you Medicine?” can end with “You should really call Orthopedics.” Meanwhile, “Medicine” and “Orthopedics” may pass each other in the hallway without recognition beyond a vague familiarity of a voice heard on the phone.

Every 10 minutes spent with a new patient is accompanied by approximately one hour of “electronic” time, which includes reading through previous medical records, reviewing laboratory data and imaging, and creating an admission note. Interns might groan as they pull up a patient’s electronic health record (EHR); irrelevant details often arise with each click of the mouse, and the cursed “copy-paste” function means that new notes often duplicate older ones. However, with time, we learn to look past the EHR’s shortcomings and appreciate several of its advantages. For example, we are now able to access test results performed outside our hospital and thus limit our repetition of investigations. We can also use the EHR to rapidly glean salient information about a patient in time-critical scenarios. This is always a satisfying process, and it makes us wonder how physicians ever practiced in the era before computers.

Today’s patients are older and sicker than ever before. Many are receiving treatments that did not exist even a decade ago. As residents, we must recognize a seemingly endless variety of drugs—a challenging but intellectually satisfying responsibility. We must also decide whether the patient’s current health state permits their continuation, or whether safer alternatives exist. Some of these decisions cannot wait until the morning.

During handover at 8 am , we often recount moments from our call shift with a sense of vigor that is only partly dulled by fatigue. We may share with pride our management of a sick patient. We may relay a touching exchange with a concerned family member. Or we may recall with satisfaction our handling of a tense situation with a colleague. Taking part in these experiences is one of the most character-building aspects of being on call. The absence of our supervisors can be unnerving at first, but we gradually begin to enjoy the sense of independence. Moreover, we feel empowered to make our patients better with the right combination of carefully selected treatments. Nothing makes us feel more like doctors.

No doubt, being on call is difficult. The next day brings a feeling of relief and accomplishment, knowing that we got through it—whether by floundering or flourishing—in one piece.

The two passages described here are personal descriptions of a typical night on-call in two different eras. Readers around the world may have a very different recollection of their own experience. Nevertheless, several aspects of being on call remain constant, such as anxiety about caring for sick patients alone, fond recollections of friends made, and relief when the morning comes. Most important, however, might be the tremendous satisfaction at the opportunity to learn and grow—to become a competent physician by testing one’s physical and intellectual limits through graded autonomy

On the other hand, certain elements of night call have undeniably changed—partly a consequence of the increased number of people involved in patient care and changing communication technology. Residents today encounter a greater number of interruptions to their work flow. Tasks that require long, continuous periods of full attention are now punctuated by texts, e-mails, calls, and pages. The EHR is often clumsy to navigate, but it can also be a veritable mine of information. Finally, although residents from the same specialty may be close friends, duty hour restrictions and remote asynchronous communication may reduce familiarity with residents from other programs.

Do these descriptions resonate with your experience of night call? Keeping in mind that the 1979 vignette is described through the rose-colored lens of nostalgia, both eras have their advantages and disadvantages. We leave it to the reader to decide what has changed (plus ça change) and what has stayed the same (plus c’est la même chose).

Acknowledgments

The authors thank Micheal A. Fifer, MD (Massachusetts General Hospital), and Timothy J. Judson, MD (UCSF), for their comments on an earlier draft of this essay.

Disclosures

The authors have nothing to disclose.

N o matter the era, few aspects of residency are more defining or memorable than overnight call. Nights can be a time of growth and learning but also of fear and uncertainty, as residents take on the responsibility of managing sick patients on their own. One of us (ASD) started his residency in 1978 at the Massachusetts General Hospital in Boston; the other two (ST and BCY) started theirs in 2016 and 2017, respectively, at the University of Toronto. In this essay, we reflect on our experiences of night call separated by 40 years, highlighting what has changed and what has stayed the same.

At 6 pm, a calm overtook the hospital as the daytime staff emptied out of the building. The only remaining residents were those on call for the night. Each team had one resident and one medical student responsible for about 20 inpatients. Teams also admitted new patients from the emergency department (ED). Since there were three teams who rotated the admissions, we were able to spend a part of our night on the inpatient ward. Most of the new patients had been thoroughly evaluated by a medical resident in the ED before we saw them, giving us a head start on eliciting their stories, performing physical examinations, reviewing the laboratory workup, and generating plans to present to the attending physician (who was called “the visit”) the next morning at 10 am .

We carried one pager that was about 7 inches long and 2 inches wide clipped to the waist of our pants. It could only make a beep; we then had to call the page operator to find out who wanted us. However, the pages were relatively few. Nurses called only when a patient was unstable, and other residents called only when a new patient was ready in the emergency department. At 9 pm , the laboratory data for the day were delivered to the ward nursing stations on computer-generated paper. Our job was to separate the pages connected by serrated breaks, review the results, and then file the pages in the charts. The nurses were aware of this routine, so they saved their questions for our presence on the wards, reducing the need to page us. At 10 pm , residents from all services went to the cafeteria for the “10 o’clock meal” when the food was free.We learned early in the year to drop everything at 10 pm ; otherwise, we did not eat. The social aspect of the group meal was comforting, but compared with today, the group was much more homogeneous and therefore less interesting. There were several women medical residents (although almost none in surgery), but very few minorities, and no openly gay residents.

Gathering data about patients prior to the current hospitalization required reviewing the “old chart,” which had to be delivered from patient records but was generally available when the patient was still in the ED. It contained typed discharge summaries and progress notes often handwritten by coresidents whom we knew. The handwriting was often difficult to read, outpatient notes were not included, and information from other hospitals was absent—but despite these deficiencies, we somehow managed just fine.

The patients on the inpatient ward were mostly stable, but more importantly, we had very few medications and tests to order. I recall prescribing fewer than 20 drugs—furosemide, hydrochlorothiazide, penicillins, cephalosporins, gentamicin, isoniazid, lidocaine, nitroglycerin, aminophylline, alpha-methyldopa, clonidine, propranolol, digoxin, hydralazine, indomethacin, steroids, and morphine. Orders for tests and imaging had to be physically written in the chart and could not be inputted remotely, which was a nuisance when we were away from the ward. However, we rarely ordered any imaging beyond plain radiographs at night. We did draw arterial blood gases and venous blood, administer oxygen, insert intravenous and central lines, take electrocardiograms, and perform urinalyses by microscopy. We did all these tasks ourselves for patients on the “ward service” (as opposed to the “private service”, which had to do with the type of insurance the patients possessed). As a result, we became experts in both blood drawing and intravenous line insertion—skills that might be less familiar to today’s residents.

Of course, patients did get acutely ill during the night. I recall intubating, cardioverting, performing phlebotomy to alleviate pulmonary edema, sending patients to surgery, and pronouncing death. Nevertheless, we often got sleep, and sometimes, several hours in a row. I had a rule; I always took a shower the next morning and put on clean clothes (we stayed until 5 pm , making the shifts 33.5 hours long). There was a camaraderie that existed between all of us at night. We were supportive, friendly, and knew each other by name, and more.

We were often frightened by the responsibility of managing sick patients alone. On particularly challenging nights, we would record our fears and feelings in a “night call diary” in one of the conference rooms—generally at 4 am . Some entries became legendary as people read and reread those months and years later. Mornings always brought a sense of relief and accomplishment, because when the sun came up, we knew that the other residents would not be far behind; when they arrived, we could tell our stories and get help.

There was definitely competitiveness to the work. Those who responded quickly to deteriorating patients were applauded; those who did not really know what to do were subtly disdained. However, over time, we all got the hang of it, and this led to a growing confidence that we were indeed doctors. The graded autonomy afforded by night call was a crucial part of that journey.

At 6 pm , the on-call residents assemble in the ED, where we would spend the remainder of the night and early morning admitting new patients to the hospital. A night team consists of a senior resident, three junior residents, and two medical students, with each resident being responsible for approximately 20 inpatients. Overnight coverage of the ward mostly occurs remotely; since the ED is often so busy, we address most of the issues through a computer or over the phone. Only in rare cases, such as when a patient is unstable or a death has occurred, do we deal with the matter in person.

To enable rapid remote responses, we each carry an assortment of devices on our waists or lanyards and in our pockets, such as a personal pager, ED consult pager, code blue pager, and hospital-issued smartphones capable of receiving pages, text messages, phone calls, and e-mails. Nurses, pharmacists, and other consultants communicate with us through all of these channels. Few of these interactions occur face-to-face. To our frustration, encounters with patients are frequently interrupted by a stream of beeps, rings, and vibrations—irrespective of whether we are having a difficult discussion about goals of care or performing a delicate procedure.

The ED contains a work space dedicated for residents to enter electronic orders, type notes, and review new admissions. Between consults, we try to discuss exciting cases and provide teaching to the medical students and interns, which we enjoy. Dinner is generally devoured while inputting orders. In exceptional circumstances, a brief reprieve from pages may allow the on-call team to share a meal. Depending on our role, sleep may be possible on certain nights but is never guaranteed. Moments spent with the on-call team—all of us learning, commiserating, and growing together—are some of the most memorable of residency, and many of us become close friends by the end of the rotation.

However, apart from these few familiar faces, we rarely get acquainted with the nurses or residents from other services. Many often refer to themselves by specialty rather than name and phone calls that begin with “Are you Medicine?” can end with “You should really call Orthopedics.” Meanwhile, “Medicine” and “Orthopedics” may pass each other in the hallway without recognition beyond a vague familiarity of a voice heard on the phone.

Every 10 minutes spent with a new patient is accompanied by approximately one hour of “electronic” time, which includes reading through previous medical records, reviewing laboratory data and imaging, and creating an admission note. Interns might groan as they pull up a patient’s electronic health record (EHR); irrelevant details often arise with each click of the mouse, and the cursed “copy-paste” function means that new notes often duplicate older ones. However, with time, we learn to look past the EHR’s shortcomings and appreciate several of its advantages. For example, we are now able to access test results performed outside our hospital and thus limit our repetition of investigations. We can also use the EHR to rapidly glean salient information about a patient in time-critical scenarios. This is always a satisfying process, and it makes us wonder how physicians ever practiced in the era before computers.

Today’s patients are older and sicker than ever before. Many are receiving treatments that did not exist even a decade ago. As residents, we must recognize a seemingly endless variety of drugs—a challenging but intellectually satisfying responsibility. We must also decide whether the patient’s current health state permits their continuation, or whether safer alternatives exist. Some of these decisions cannot wait until the morning.

During handover at 8 am , we often recount moments from our call shift with a sense of vigor that is only partly dulled by fatigue. We may share with pride our management of a sick patient. We may relay a touching exchange with a concerned family member. Or we may recall with satisfaction our handling of a tense situation with a colleague. Taking part in these experiences is one of the most character-building aspects of being on call. The absence of our supervisors can be unnerving at first, but we gradually begin to enjoy the sense of independence. Moreover, we feel empowered to make our patients better with the right combination of carefully selected treatments. Nothing makes us feel more like doctors.

No doubt, being on call is difficult. The next day brings a feeling of relief and accomplishment, knowing that we got through it—whether by floundering or flourishing—in one piece.

The two passages described here are personal descriptions of a typical night on-call in two different eras. Readers around the world may have a very different recollection of their own experience. Nevertheless, several aspects of being on call remain constant, such as anxiety about caring for sick patients alone, fond recollections of friends made, and relief when the morning comes. Most important, however, might be the tremendous satisfaction at the opportunity to learn and grow—to become a competent physician by testing one’s physical and intellectual limits through graded autonomy

On the other hand, certain elements of night call have undeniably changed—partly a consequence of the increased number of people involved in patient care and changing communication technology. Residents today encounter a greater number of interruptions to their work flow. Tasks that require long, continuous periods of full attention are now punctuated by texts, e-mails, calls, and pages. The EHR is often clumsy to navigate, but it can also be a veritable mine of information. Finally, although residents from the same specialty may be close friends, duty hour restrictions and remote asynchronous communication may reduce familiarity with residents from other programs.

Do these descriptions resonate with your experience of night call? Keeping in mind that the 1979 vignette is described through the rose-colored lens of nostalgia, both eras have their advantages and disadvantages. We leave it to the reader to decide what has changed (plus ça change) and what has stayed the same (plus c’est la même chose).

Acknowledgments

The authors thank Micheal A. Fifer, MD (Massachusetts General Hospital), and Timothy J. Judson, MD (UCSF), for their comments on an earlier draft of this essay.

Disclosures

The authors have nothing to disclose.

N o matter the era, few aspects of residency are more defining or memorable than overnight call. Nights can be a time of growth and learning but also of fear and uncertainty, as residents take on the responsibility of managing sick patients on their own. One of us (ASD) started his residency in 1978 at the Massachusetts General Hospital in Boston; the other two (ST and BCY) started theirs in 2016 and 2017, respectively, at the University of Toronto. In this essay, we reflect on our experiences of night call separated by 40 years, highlighting what has changed and what has stayed the same.

At 6 pm, a calm overtook the hospital as the daytime staff emptied out of the building. The only remaining residents were those on call for the night. Each team had one resident and one medical student responsible for about 20 inpatients. Teams also admitted new patients from the emergency department (ED). Since there were three teams who rotated the admissions, we were able to spend a part of our night on the inpatient ward. Most of the new patients had been thoroughly evaluated by a medical resident in the ED before we saw them, giving us a head start on eliciting their stories, performing physical examinations, reviewing the laboratory workup, and generating plans to present to the attending physician (who was called “the visit”) the next morning at 10 am .

We carried one pager that was about 7 inches long and 2 inches wide clipped to the waist of our pants. It could only make a beep; we then had to call the page operator to find out who wanted us. However, the pages were relatively few. Nurses called only when a patient was unstable, and other residents called only when a new patient was ready in the emergency department. At 9 pm , the laboratory data for the day were delivered to the ward nursing stations on computer-generated paper. Our job was to separate the pages connected by serrated breaks, review the results, and then file the pages in the charts. The nurses were aware of this routine, so they saved their questions for our presence on the wards, reducing the need to page us. At 10 pm , residents from all services went to the cafeteria for the “10 o’clock meal” when the food was free.We learned early in the year to drop everything at 10 pm ; otherwise, we did not eat. The social aspect of the group meal was comforting, but compared with today, the group was much more homogeneous and therefore less interesting. There were several women medical residents (although almost none in surgery), but very few minorities, and no openly gay residents.

Gathering data about patients prior to the current hospitalization required reviewing the “old chart,” which had to be delivered from patient records but was generally available when the patient was still in the ED. It contained typed discharge summaries and progress notes often handwritten by coresidents whom we knew. The handwriting was often difficult to read, outpatient notes were not included, and information from other hospitals was absent—but despite these deficiencies, we somehow managed just fine.

The patients on the inpatient ward were mostly stable, but more importantly, we had very few medications and tests to order. I recall prescribing fewer than 20 drugs—furosemide, hydrochlorothiazide, penicillins, cephalosporins, gentamicin, isoniazid, lidocaine, nitroglycerin, aminophylline, alpha-methyldopa, clonidine, propranolol, digoxin, hydralazine, indomethacin, steroids, and morphine. Orders for tests and imaging had to be physically written in the chart and could not be inputted remotely, which was a nuisance when we were away from the ward. However, we rarely ordered any imaging beyond plain radiographs at night. We did draw arterial blood gases and venous blood, administer oxygen, insert intravenous and central lines, take electrocardiograms, and perform urinalyses by microscopy. We did all these tasks ourselves for patients on the “ward service” (as opposed to the “private service”, which had to do with the type of insurance the patients possessed). As a result, we became experts in both blood drawing and intravenous line insertion—skills that might be less familiar to today’s residents.

Of course, patients did get acutely ill during the night. I recall intubating, cardioverting, performing phlebotomy to alleviate pulmonary edema, sending patients to surgery, and pronouncing death. Nevertheless, we often got sleep, and sometimes, several hours in a row. I had a rule; I always took a shower the next morning and put on clean clothes (we stayed until 5 pm , making the shifts 33.5 hours long). There was a camaraderie that existed between all of us at night. We were supportive, friendly, and knew each other by name, and more.

We were often frightened by the responsibility of managing sick patients alone. On particularly challenging nights, we would record our fears and feelings in a “night call diary” in one of the conference rooms—generally at 4 am . Some entries became legendary as people read and reread those months and years later. Mornings always brought a sense of relief and accomplishment, because when the sun came up, we knew that the other residents would not be far behind; when they arrived, we could tell our stories and get help.

There was definitely competitiveness to the work. Those who responded quickly to deteriorating patients were applauded; those who did not really know what to do were subtly disdained. However, over time, we all got the hang of it, and this led to a growing confidence that we were indeed doctors. The graded autonomy afforded by night call was a crucial part of that journey.

At 6 pm , the on-call residents assemble in the ED, where we would spend the remainder of the night and early morning admitting new patients to the hospital. A night team consists of a senior resident, three junior residents, and two medical students, with each resident being responsible for approximately 20 inpatients. Overnight coverage of the ward mostly occurs remotely; since the ED is often so busy, we address most of the issues through a computer or over the phone. Only in rare cases, such as when a patient is unstable or a death has occurred, do we deal with the matter in person.

To enable rapid remote responses, we each carry an assortment of devices on our waists or lanyards and in our pockets, such as a personal pager, ED consult pager, code blue pager, and hospital-issued smartphones capable of receiving pages, text messages, phone calls, and e-mails. Nurses, pharmacists, and other consultants communicate with us through all of these channels. Few of these interactions occur face-to-face. To our frustration, encounters with patients are frequently interrupted by a stream of beeps, rings, and vibrations—irrespective of whether we are having a difficult discussion about goals of care or performing a delicate procedure.

The ED contains a work space dedicated for residents to enter electronic orders, type notes, and review new admissions. Between consults, we try to discuss exciting cases and provide teaching to the medical students and interns, which we enjoy. Dinner is generally devoured while inputting orders. In exceptional circumstances, a brief reprieve from pages may allow the on-call team to share a meal. Depending on our role, sleep may be possible on certain nights but is never guaranteed. Moments spent with the on-call team—all of us learning, commiserating, and growing together—are some of the most memorable of residency, and many of us become close friends by the end of the rotation.

However, apart from these few familiar faces, we rarely get acquainted with the nurses or residents from other services. Many often refer to themselves by specialty rather than name and phone calls that begin with “Are you Medicine?” can end with “You should really call Orthopedics.” Meanwhile, “Medicine” and “Orthopedics” may pass each other in the hallway without recognition beyond a vague familiarity of a voice heard on the phone.

Every 10 minutes spent with a new patient is accompanied by approximately one hour of “electronic” time, which includes reading through previous medical records, reviewing laboratory data and imaging, and creating an admission note. Interns might groan as they pull up a patient’s electronic health record (EHR); irrelevant details often arise with each click of the mouse, and the cursed “copy-paste” function means that new notes often duplicate older ones. However, with time, we learn to look past the EHR’s shortcomings and appreciate several of its advantages. For example, we are now able to access test results performed outside our hospital and thus limit our repetition of investigations. We can also use the EHR to rapidly glean salient information about a patient in time-critical scenarios. This is always a satisfying process, and it makes us wonder how physicians ever practiced in the era before computers.

Today’s patients are older and sicker than ever before. Many are receiving treatments that did not exist even a decade ago. As residents, we must recognize a seemingly endless variety of drugs—a challenging but intellectually satisfying responsibility. We must also decide whether the patient’s current health state permits their continuation, or whether safer alternatives exist. Some of these decisions cannot wait until the morning.

During handover at 8 am , we often recount moments from our call shift with a sense of vigor that is only partly dulled by fatigue. We may share with pride our management of a sick patient. We may relay a touching exchange with a concerned family member. Or we may recall with satisfaction our handling of a tense situation with a colleague. Taking part in these experiences is one of the most character-building aspects of being on call. The absence of our supervisors can be unnerving at first, but we gradually begin to enjoy the sense of independence. Moreover, we feel empowered to make our patients better with the right combination of carefully selected treatments. Nothing makes us feel more like doctors.

No doubt, being on call is difficult. The next day brings a feeling of relief and accomplishment, knowing that we got through it—whether by floundering or flourishing—in one piece.

The two passages described here are personal descriptions of a typical night on-call in two different eras. Readers around the world may have a very different recollection of their own experience. Nevertheless, several aspects of being on call remain constant, such as anxiety about caring for sick patients alone, fond recollections of friends made, and relief when the morning comes. Most important, however, might be the tremendous satisfaction at the opportunity to learn and grow—to become a competent physician by testing one’s physical and intellectual limits through graded autonomy

On the other hand, certain elements of night call have undeniably changed—partly a consequence of the increased number of people involved in patient care and changing communication technology. Residents today encounter a greater number of interruptions to their work flow. Tasks that require long, continuous periods of full attention are now punctuated by texts, e-mails, calls, and pages. The EHR is often clumsy to navigate, but it can also be a veritable mine of information. Finally, although residents from the same specialty may be close friends, duty hour restrictions and remote asynchronous communication may reduce familiarity with residents from other programs.

Do these descriptions resonate with your experience of night call? Keeping in mind that the 1979 vignette is described through the rose-colored lens of nostalgia, both eras have their advantages and disadvantages. We leave it to the reader to decide what has changed (plus ça change) and what has stayed the same (plus c’est la même chose).

Acknowledgments

The authors thank Micheal A. Fifer, MD (Massachusetts General Hospital), and Timothy J. Judson, MD (UCSF), for their comments on an earlier draft of this essay.

Disclosures

The authors have nothing to disclose.

Polypharmacy, the practice of taking multiple medications to manage health conditions, is common for children. Many children today have a higher burden chronic illness and an increasing number of pharmaceuticals—often delivered in various doses throughout the day. Polypharmacy has been linked to a variety of pediatric and adult outcomes, including medication errors and readmission.^1-3 Consequently, the Society of Hospital Medicine recognizes polypharmacy as a risk factor for readmission for adult populations.⁴ These adverse outcomes are related to both the human elements of polypharmacy (eg, cognitive burden, adherence) and the pharmacologic elements, including drug–drug interactions. For many children, the safety implications of polypharmacy may be more consequential due to the reliance of multiple caregivers to administer medications, which requires additional coordination to ensure that medications are administered and not duplicated. Dual administration of the same medication by both parents is the most common reason for pediatric calls to Poison Control Centers.⁵ Yet, there is a paucity of research in this area, with most of the pediatric literature focusing on the outpatient setting and specific populations, including epilepsy and mental health.^6-8

How providers, patients, and families translate medication lists to counts of medications—and hence the burden of polypharmacy—is not clearly or consistently described. Often in studies of polypharmacy, researchers utilize medication claims data to count the number of medications a patient has filled from the pharmacy. However, in routine clinical practice, clinicians rarely have access to medication claims and thus rely on patient or family report, which may or may not match the list of medications in the patients’ medical records.

Therefore, linking polypharmacy research to the pragmatic complexities of clinical care requires greater clarity and consistent application of concepts. At hospital discharge, families receive a list of medications to take, including home medications to resume as well as newly prescribed medications. However, not all medications are equally essential to patients’ care regarding importance of administration (eg, hydrocortisone ointment versus an anticonvulsant medication). Patients, parents, and caregivers are ultimately responsible for determining which medications to prioritize and administer.

Although there is no standard numerical definition for how to identify polypharmacy, five medications is commonly considered the threshold for polypharmacy.⁹ A recent review of the pediatric polypharmacy literature suggested a lower threshold, with any two concurrent medications for at least a day.⁷ Yet, the best approach to “count” medications at hospital discharge is unclear. The simplest method is to tally the number of medications listed in the discharge summary. However, medications are sometimes listed twice due to different dosages administered at different times. Frequently, medications are prescribed on an as-needed basis; these medications could be administered routinely or very infrequently (eg, epinephrine for anaphylaxis). Over-the-counter medications are also sometimes included in discharge summaries and consideration should be given as to whether these medications count toward measures of polypharmacy. Over-the-counter medications would not be counted by a polypharmacy measure that relies on claims data if those medications are not paid by the insurer.

We sought consensus on how to count discharge medications through a series of informal interviews with hospitalists, nurses, and parents. We asked the seemingly simple question, “How many medications is this child on?” across a variety of scenarios (Figure). For panel A, all stakeholders agreed that this medication list includes two medications. All other scenarios elicited disagreement. For panel B, many people responded three medications, but others (often physicians) counted only clindamycin and therefore responded one medication.

Disclosures

Dr. Auger has nothing to disclose. Dr. Shah is the Editor-in-Chief of the Journal of Hospital Medicine. Dr. Davis has nothing to disclose. Dr. Brady reports grants from Agency for Healthcare Research and Quality, outside the submitted work.

Funding

This project is supported by a grant from the Agency for Healthcare Research and Quality (1K08HS204735-01A1).

Polypharmacy, the practice of taking multiple medications to manage health conditions, is common for children. Many children today have a higher burden chronic illness and an increasing number of pharmaceuticals—often delivered in various doses throughout the day. Polypharmacy has been linked to a variety of pediatric and adult outcomes, including medication errors and readmission.^1-3 Consequently, the Society of Hospital Medicine recognizes polypharmacy as a risk factor for readmission for adult populations.⁴ These adverse outcomes are related to both the human elements of polypharmacy (eg, cognitive burden, adherence) and the pharmacologic elements, including drug–drug interactions. For many children, the safety implications of polypharmacy may be more consequential due to the reliance of multiple caregivers to administer medications, which requires additional coordination to ensure that medications are administered and not duplicated. Dual administration of the same medication by both parents is the most common reason for pediatric calls to Poison Control Centers.⁵ Yet, there is a paucity of research in this area, with most of the pediatric literature focusing on the outpatient setting and specific populations, including epilepsy and mental health.^6-8

How providers, patients, and families translate medication lists to counts of medications—and hence the burden of polypharmacy—is not clearly or consistently described. Often in studies of polypharmacy, researchers utilize medication claims data to count the number of medications a patient has filled from the pharmacy. However, in routine clinical practice, clinicians rarely have access to medication claims and thus rely on patient or family report, which may or may not match the list of medications in the patients’ medical records.

Therefore, linking polypharmacy research to the pragmatic complexities of clinical care requires greater clarity and consistent application of concepts. At hospital discharge, families receive a list of medications to take, including home medications to resume as well as newly prescribed medications. However, not all medications are equally essential to patients’ care regarding importance of administration (eg, hydrocortisone ointment versus an anticonvulsant medication). Patients, parents, and caregivers are ultimately responsible for determining which medications to prioritize and administer.

Although there is no standard numerical definition for how to identify polypharmacy, five medications is commonly considered the threshold for polypharmacy.⁹ A recent review of the pediatric polypharmacy literature suggested a lower threshold, with any two concurrent medications for at least a day.⁷ Yet, the best approach to “count” medications at hospital discharge is unclear. The simplest method is to tally the number of medications listed in the discharge summary. However, medications are sometimes listed twice due to different dosages administered at different times. Frequently, medications are prescribed on an as-needed basis; these medications could be administered routinely or very infrequently (eg, epinephrine for anaphylaxis). Over-the-counter medications are also sometimes included in discharge summaries and consideration should be given as to whether these medications count toward measures of polypharmacy. Over-the-counter medications would not be counted by a polypharmacy measure that relies on claims data if those medications are not paid by the insurer.

We sought consensus on how to count discharge medications through a series of informal interviews with hospitalists, nurses, and parents. We asked the seemingly simple question, “How many medications is this child on?” across a variety of scenarios (Figure). For panel A, all stakeholders agreed that this medication list includes two medications. All other scenarios elicited disagreement. For panel B, many people responded three medications, but others (often physicians) counted only clindamycin and therefore responded one medication.

Disclosures

Dr. Auger has nothing to disclose. Dr. Shah is the Editor-in-Chief of the Journal of Hospital Medicine. Dr. Davis has nothing to disclose. Dr. Brady reports grants from Agency for Healthcare Research and Quality, outside the submitted work.

Funding

This project is supported by a grant from the Agency for Healthcare Research and Quality (1K08HS204735-01A1).

Polypharmacy, the practice of taking multiple medications to manage health conditions, is common for children. Many children today have a higher burden chronic illness and an increasing number of pharmaceuticals—often delivered in various doses throughout the day. Polypharmacy has been linked to a variety of pediatric and adult outcomes, including medication errors and readmission.^1-3 Consequently, the Society of Hospital Medicine recognizes polypharmacy as a risk factor for readmission for adult populations.⁴ These adverse outcomes are related to both the human elements of polypharmacy (eg, cognitive burden, adherence) and the pharmacologic elements, including drug–drug interactions. For many children, the safety implications of polypharmacy may be more consequential due to the reliance of multiple caregivers to administer medications, which requires additional coordination to ensure that medications are administered and not duplicated. Dual administration of the same medication by both parents is the most common reason for pediatric calls to Poison Control Centers.⁵ Yet, there is a paucity of research in this area, with most of the pediatric literature focusing on the outpatient setting and specific populations, including epilepsy and mental health.^6-8

How providers, patients, and families translate medication lists to counts of medications—and hence the burden of polypharmacy—is not clearly or consistently described. Often in studies of polypharmacy, researchers utilize medication claims data to count the number of medications a patient has filled from the pharmacy. However, in routine clinical practice, clinicians rarely have access to medication claims and thus rely on patient or family report, which may or may not match the list of medications in the patients’ medical records.

Therefore, linking polypharmacy research to the pragmatic complexities of clinical care requires greater clarity and consistent application of concepts. At hospital discharge, families receive a list of medications to take, including home medications to resume as well as newly prescribed medications. However, not all medications are equally essential to patients’ care regarding importance of administration (eg, hydrocortisone ointment versus an anticonvulsant medication). Patients, parents, and caregivers are ultimately responsible for determining which medications to prioritize and administer.

Although there is no standard numerical definition for how to identify polypharmacy, five medications is commonly considered the threshold for polypharmacy.⁹ A recent review of the pediatric polypharmacy literature suggested a lower threshold, with any two concurrent medications for at least a day.⁷ Yet, the best approach to “count” medications at hospital discharge is unclear. The simplest method is to tally the number of medications listed in the discharge summary. However, medications are sometimes listed twice due to different dosages administered at different times. Frequently, medications are prescribed on an as-needed basis; these medications could be administered routinely or very infrequently (eg, epinephrine for anaphylaxis). Over-the-counter medications are also sometimes included in discharge summaries and consideration should be given as to whether these medications count toward measures of polypharmacy. Over-the-counter medications would not be counted by a polypharmacy measure that relies on claims data if those medications are not paid by the insurer.

We sought consensus on how to count discharge medications through a series of informal interviews with hospitalists, nurses, and parents. We asked the seemingly simple question, “How many medications is this child on?” across a variety of scenarios (Figure). For panel A, all stakeholders agreed that this medication list includes two medications. All other scenarios elicited disagreement. For panel B, many people responded three medications, but others (often physicians) counted only clindamycin and therefore responded one medication.

Disclosures

Dr. Auger has nothing to disclose. Dr. Shah is the Editor-in-Chief of the Journal of Hospital Medicine. Dr. Davis has nothing to disclose. Dr. Brady reports grants from Agency for Healthcare Research and Quality, outside the submitted work.

Funding

This project is supported by a grant from the Agency for Healthcare Research and Quality (1K08HS204735-01A1).

The United States health system has been criticized for its overuse of aggressive and medically ineffective life-sustaining therapies (LST).¹ Some professional societies have elevated dialog about end-of-life (EOL) care to a quality measure,² expecting that more open discussion will achieve more “goal-concordant care”³ and appropriate use of LST. However, even when Advanced Directives (AD) or Physician Orders for Life-Sustaining Therapy (POLST) have been created, their directions are not always followed in the hospital. This perspective discusses how preventable errors allow for use of LST even when patients designated it as unwanted. Two cases, chosen from several similar ones, are highlighted, demonstrating both human and system errors.

During the time of these events, the hospital policy required admission orders to contain a “code status” designation in the electronic medical record (EMR). All active and historical code status orders were listed chronologically and all AD and POLST documents were scanned into a special section of the EMR. Hospital policy, consistent with professional society guidelines,^4,5 stated that patients with AD/POLST limiting EOL support should have individualized discussion about resuscitation options in the event of a periprocedural critical event. Automatic suspension or reinstatement of limited code orders was not permitted.

A 62-year-old woman with refractory heart failure was admitted with recurrence. The admitting code order was “initiate CPR/intubation” even though a POLST order written 10 months earlier indicating “do not intubate” was visible in the EMR. A more recent POLST indicating “No CPR/No intubation” accompanied the patient in the ambulance and was placed at bedside, but not scanned. There was no documented discussion of code status that might have explained the POLST/code order disparity. Notably, during two prior admissions within the year, “full code” orders had also been placed. On the fifth hospital day, the patient was found in respiratory distress and unresponsive. A “code” was called. ICU staff, after confirming full code status, intubated the patient emergently and commenced other invasive ICU interventions. Family members brought the preexisting POLST to medical attention within hours of the code but could not agree on immediate extubation. Over the next week, multiple prognosis discussions were held with the patient (when responsive) and family. Ultimately, the patient failed to improve and indicated a desire to be extubated, dying a few hours later.

A 94-year-old woman was admitted from assisted living with a traumatic subcapital femur fracture. Admission code orders were “initiate CPR/intubation” despite the presence in the EMR of a POLST ordering “no CPR/no intubation.” The patient underwent hemiarthroplasty. There was no documented discussion of AD/POLST by the surgeon, anesthesiologist, or other operating room personnel even though the patient was alert and competent. On postoperative day one, she was found to be bradycardic and hypotensive. A code was called. After confirming full code status in the EMR, cardiac compressions were begun, followed by intubation. Immediately afterward, family members indicated that the patient had a POLST limiting EOL care. When the healthcare proxy was reached hours later, she directed the patient be extubated. The patient died 16 minutes later.

Data on the frequency of unwanted CPR/intubation due to medical error are scarce. In the US, several lawsuits arising from unwanted CPR and intubation have achieved notoriety, but registries of legal cases⁶ probably underestimate the frequency of this harm. In a study of incorrect code status orders at Canadian hospitals, 35% of 308 patients with limited care preferences had full code orders in the chart.⁷ It is unclear how many of these expressed preferences also had legal documents available. There was considerable variability among hospitals, suggesting that local practices and culture were important factors.

Spot audits of 121 of our own patient charts (median age 77 years) on oncology, geriatrics, and cardiac units at our institution found 36 (30%) with AD/POLST that clearly limited life-sustaining treatments. Of these, 14 (39%) had discrepant full code orders. A review of these discrepant orders showed no medical documentation to indicate that the discrepancy was purposeful.

A root cause analysis (RCA) of cases of unwanted resuscitation, including interviews with involved nurses, medical staff, and operating room, hospitalist, and medical informatics leadership, revealed several types of error, both human and system. These pitfalls are probably common to several hospitals, and the solutions developed may be helpful as well (Table).

Haste leads to poor communication with the patient and family. Emergency departments and admitting services can be hectic. Clinicians facing time and acuity pressure may give short shrift to the essential activity of validating patient choices, regardless of whether an AD or POLST is available. Poor communication was the major factor allowing for discrepancy in the Canadian study.⁷ Avoiding prognostic frankness is a well-known coping strategy for both clinicians and patients^8,9 but in all these cases, that obstacle had been overcome earlier in the clinical course of disease, leaving inattention or haste as the most likely culprit.

“It is not our hospital culture to surveille for code status discrepancies, discuss appropriateness on rounds or at sign out.”

In all reviewed cases of unwanted resuscitation, numerous admitting or attending physicians failed to discuss LST meaningfully despite clinical scenarios that were associated with poor prognosis and should have provoked discussion about medical ineffectiveness. The admitting hospitalist in case 2 stated later that she had listed code choices for the patient who chose full code despite having a POLST stating otherwise. However, that discussion was not in depth, not reviewed for match to her POLST, and not documented.

Moreover, all the cases of AD/POLST and code status discrepancy were on nursing units with daily multidisciplinary rounds and where there had been twice-daily nurse-to-nurse and medical staff–to–medical staff sign out. Queries about code status appropriateness and checks for discrepant AD/POLST and code orders were not standard work. Thus, the medical error was perpetuated.

Analysis of cases of unwanted intubation in postoperative cases indicated that contrary to guidelines,^4,5 careful code status review was not part of the preoperative checklist or presurgical discussion.

The EMR is a well-recognized source of potential medical error.^10,11 Clinicians may rely on the EMR for code status history or as a repository of relevant documents. These are important as a starting place for code status discussions, especially since patients and proxies often cannot accurately recall the existence of an AD/POLST or understand the options being presented.^9,12 In case 1, clinicians partially relied upon the erroneous historical code status already in the chart from two prior admissions. This is a dangerous practice since code status choices have several options and depend upon the clinical situation. In the case of paper AD/POLST documents, the EMR is set up poorly to help the medical team find relevant documents. Furthermore, the EMR clinical decision support capabilities do not interact with paper documents, so no assistance in pointing out discrepancies is available. In addition, the scanning process itself can be problematic since scanning of paper documents was not performed until after the patient was discharged, thus hiding the most up-to-date documents from the personnel even if they had sought them. Moreover, our scanning process had been labeling documents with the date of scanning and not the date of completion, making it difficult to find the “active” order.

Interviews with different clinicians revealed widespread knowledge deficits, including appreciation of the POLST as durable across different medical institutions, effective differences between POLST and AD, location of POLST/AD within the EMR, recommendations of professional society guidelines on suspending DNR for procedures, hospital policy on same, the need to check for updates in bedside paper documents, and whether family members can overrule patients’ stated wishes. Education tends to be the most common form of recommendation after RCA and may be the least efficacious in risk mitigation,¹³ but in this case, education reinforced by new EMR capabilities was an essential part of the solutions bundle (Table).

AD/POLST and similar tools are complex, and the choices are not binary. They are subject to change depending upon the medical context and the patient status and may be poorly understood by patients and clinicians.¹⁴ Accordingly, writing a goal-concordant code status order demands time and attention and as much nuanced medical judgment as any other medical problem faced by hospital-based clinicians. Though time-consuming, discussion with the patient or the surrogate should be considered as “standard work.” To facilitate this, a mandatory affirmative statement about review of LST choices was added to admission templates, procedural areas, and clinician sign outs (Table).

Unwanted, and therefore unwarranted, resuscitation violates autonomy and creates distress, anger, and distrust among patients and families. The distress extends also to frontline clinicians who are committed to “do no harm” in every other aspect of their professional lives.

Respecting and translating patients’ AD/POLST or similar tools into goal-concordant code status order is an essential professional commitment. Respect for patient safety and autonomy demands that we do it well, teach it well, and hold each other accountable.

Disclosures

The authors have nothing disclose.

The United States health system has been criticized for its overuse of aggressive and medically ineffective life-sustaining therapies (LST).¹ Some professional societies have elevated dialog about end-of-life (EOL) care to a quality measure,² expecting that more open discussion will achieve more “goal-concordant care”³ and appropriate use of LST. However, even when Advanced Directives (AD) or Physician Orders for Life-Sustaining Therapy (POLST) have been created, their directions are not always followed in the hospital. This perspective discusses how preventable errors allow for use of LST even when patients designated it as unwanted. Two cases, chosen from several similar ones, are highlighted, demonstrating both human and system errors.

During the time of these events, the hospital policy required admission orders to contain a “code status” designation in the electronic medical record (EMR). All active and historical code status orders were listed chronologically and all AD and POLST documents were scanned into a special section of the EMR. Hospital policy, consistent with professional society guidelines,^4,5 stated that patients with AD/POLST limiting EOL support should have individualized discussion about resuscitation options in the event of a periprocedural critical event. Automatic suspension or reinstatement of limited code orders was not permitted.

A 62-year-old woman with refractory heart failure was admitted with recurrence. The admitting code order was “initiate CPR/intubation” even though a POLST order written 10 months earlier indicating “do not intubate” was visible in the EMR. A more recent POLST indicating “No CPR/No intubation” accompanied the patient in the ambulance and was placed at bedside, but not scanned. There was no documented discussion of code status that might have explained the POLST/code order disparity. Notably, during two prior admissions within the year, “full code” orders had also been placed. On the fifth hospital day, the patient was found in respiratory distress and unresponsive. A “code” was called. ICU staff, after confirming full code status, intubated the patient emergently and commenced other invasive ICU interventions. Family members brought the preexisting POLST to medical attention within hours of the code but could not agree on immediate extubation. Over the next week, multiple prognosis discussions were held with the patient (when responsive) and family. Ultimately, the patient failed to improve and indicated a desire to be extubated, dying a few hours later.

A 94-year-old woman was admitted from assisted living with a traumatic subcapital femur fracture. Admission code orders were “initiate CPR/intubation” despite the presence in the EMR of a POLST ordering “no CPR/no intubation.” The patient underwent hemiarthroplasty. There was no documented discussion of AD/POLST by the surgeon, anesthesiologist, or other operating room personnel even though the patient was alert and competent. On postoperative day one, she was found to be bradycardic and hypotensive. A code was called. After confirming full code status in the EMR, cardiac compressions were begun, followed by intubation. Immediately afterward, family members indicated that the patient had a POLST limiting EOL care. When the healthcare proxy was reached hours later, she directed the patient be extubated. The patient died 16 minutes later.

Data on the frequency of unwanted CPR/intubation due to medical error are scarce. In the US, several lawsuits arising from unwanted CPR and intubation have achieved notoriety, but registries of legal cases⁶ probably underestimate the frequency of this harm. In a study of incorrect code status orders at Canadian hospitals, 35% of 308 patients with limited care preferences had full code orders in the chart.⁷ It is unclear how many of these expressed preferences also had legal documents available. There was considerable variability among hospitals, suggesting that local practices and culture were important factors.

Spot audits of 121 of our own patient charts (median age 77 years) on oncology, geriatrics, and cardiac units at our institution found 36 (30%) with AD/POLST that clearly limited life-sustaining treatments. Of these, 14 (39%) had discrepant full code orders. A review of these discrepant orders showed no medical documentation to indicate that the discrepancy was purposeful.

A root cause analysis (RCA) of cases of unwanted resuscitation, including interviews with involved nurses, medical staff, and operating room, hospitalist, and medical informatics leadership, revealed several types of error, both human and system. These pitfalls are probably common to several hospitals, and the solutions developed may be helpful as well (Table).

Haste leads to poor communication with the patient and family. Emergency departments and admitting services can be hectic. Clinicians facing time and acuity pressure may give short shrift to the essential activity of validating patient choices, regardless of whether an AD or POLST is available. Poor communication was the major factor allowing for discrepancy in the Canadian study.⁷ Avoiding prognostic frankness is a well-known coping strategy for both clinicians and patients^8,9 but in all these cases, that obstacle had been overcome earlier in the clinical course of disease, leaving inattention or haste as the most likely culprit.

“It is not our hospital culture to surveille for code status discrepancies, discuss appropriateness on rounds or at sign out.”

In all reviewed cases of unwanted resuscitation, numerous admitting or attending physicians failed to discuss LST meaningfully despite clinical scenarios that were associated with poor prognosis and should have provoked discussion about medical ineffectiveness. The admitting hospitalist in case 2 stated later that she had listed code choices for the patient who chose full code despite having a POLST stating otherwise. However, that discussion was not in depth, not reviewed for match to her POLST, and not documented.

Moreover, all the cases of AD/POLST and code status discrepancy were on nursing units with daily multidisciplinary rounds and where there had been twice-daily nurse-to-nurse and medical staff–to–medical staff sign out. Queries about code status appropriateness and checks for discrepant AD/POLST and code orders were not standard work. Thus, the medical error was perpetuated.

Analysis of cases of unwanted intubation in postoperative cases indicated that contrary to guidelines,^4,5 careful code status review was not part of the preoperative checklist or presurgical discussion.

The EMR is a well-recognized source of potential medical error.^10,11 Clinicians may rely on the EMR for code status history or as a repository of relevant documents. These are important as a starting place for code status discussions, especially since patients and proxies often cannot accurately recall the existence of an AD/POLST or understand the options being presented.^9,12 In case 1, clinicians partially relied upon the erroneous historical code status already in the chart from two prior admissions. This is a dangerous practice since code status choices have several options and depend upon the clinical situation. In the case of paper AD/POLST documents, the EMR is set up poorly to help the medical team find relevant documents. Furthermore, the EMR clinical decision support capabilities do not interact with paper documents, so no assistance in pointing out discrepancies is available. In addition, the scanning process itself can be problematic since scanning of paper documents was not performed until after the patient was discharged, thus hiding the most up-to-date documents from the personnel even if they had sought them. Moreover, our scanning process had been labeling documents with the date of scanning and not the date of completion, making it difficult to find the “active” order.

Interviews with different clinicians revealed widespread knowledge deficits, including appreciation of the POLST as durable across different medical institutions, effective differences between POLST and AD, location of POLST/AD within the EMR, recommendations of professional society guidelines on suspending DNR for procedures, hospital policy on same, the need to check for updates in bedside paper documents, and whether family members can overrule patients’ stated wishes. Education tends to be the most common form of recommendation after RCA and may be the least efficacious in risk mitigation,¹³ but in this case, education reinforced by new EMR capabilities was an essential part of the solutions bundle (Table).

AD/POLST and similar tools are complex, and the choices are not binary. They are subject to change depending upon the medical context and the patient status and may be poorly understood by patients and clinicians.¹⁴ Accordingly, writing a goal-concordant code status order demands time and attention and as much nuanced medical judgment as any other medical problem faced by hospital-based clinicians. Though time-consuming, discussion with the patient or the surrogate should be considered as “standard work.” To facilitate this, a mandatory affirmative statement about review of LST choices was added to admission templates, procedural areas, and clinician sign outs (Table).

Unwanted, and therefore unwarranted, resuscitation violates autonomy and creates distress, anger, and distrust among patients and families. The distress extends also to frontline clinicians who are committed to “do no harm” in every other aspect of their professional lives.

Respecting and translating patients’ AD/POLST or similar tools into goal-concordant code status order is an essential professional commitment. Respect for patient safety and autonomy demands that we do it well, teach it well, and hold each other accountable.

Disclosures

The authors have nothing disclose.

The United States health system has been criticized for its overuse of aggressive and medically ineffective life-sustaining therapies (LST).¹ Some professional societies have elevated dialog about end-of-life (EOL) care to a quality measure,² expecting that more open discussion will achieve more “goal-concordant care”³ and appropriate use of LST. However, even when Advanced Directives (AD) or Physician Orders for Life-Sustaining Therapy (POLST) have been created, their directions are not always followed in the hospital. This perspective discusses how preventable errors allow for use of LST even when patients designated it as unwanted. Two cases, chosen from several similar ones, are highlighted, demonstrating both human and system errors.

During the time of these events, the hospital policy required admission orders to contain a “code status” designation in the electronic medical record (EMR). All active and historical code status orders were listed chronologically and all AD and POLST documents were scanned into a special section of the EMR. Hospital policy, consistent with professional society guidelines,^4,5 stated that patients with AD/POLST limiting EOL support should have individualized discussion about resuscitation options in the event of a periprocedural critical event. Automatic suspension or reinstatement of limited code orders was not permitted.

A 62-year-old woman with refractory heart failure was admitted with recurrence. The admitting code order was “initiate CPR/intubation” even though a POLST order written 10 months earlier indicating “do not intubate” was visible in the EMR. A more recent POLST indicating “No CPR/No intubation” accompanied the patient in the ambulance and was placed at bedside, but not scanned. There was no documented discussion of code status that might have explained the POLST/code order disparity. Notably, during two prior admissions within the year, “full code” orders had also been placed. On the fifth hospital day, the patient was found in respiratory distress and unresponsive. A “code” was called. ICU staff, after confirming full code status, intubated the patient emergently and commenced other invasive ICU interventions. Family members brought the preexisting POLST to medical attention within hours of the code but could not agree on immediate extubation. Over the next week, multiple prognosis discussions were held with the patient (when responsive) and family. Ultimately, the patient failed to improve and indicated a desire to be extubated, dying a few hours later.

A 94-year-old woman was admitted from assisted living with a traumatic subcapital femur fracture. Admission code orders were “initiate CPR/intubation” despite the presence in the EMR of a POLST ordering “no CPR/no intubation.” The patient underwent hemiarthroplasty. There was no documented discussion of AD/POLST by the surgeon, anesthesiologist, or other operating room personnel even though the patient was alert and competent. On postoperative day one, she was found to be bradycardic and hypotensive. A code was called. After confirming full code status in the EMR, cardiac compressions were begun, followed by intubation. Immediately afterward, family members indicated that the patient had a POLST limiting EOL care. When the healthcare proxy was reached hours later, she directed the patient be extubated. The patient died 16 minutes later.

Data on the frequency of unwanted CPR/intubation due to medical error are scarce. In the US, several lawsuits arising from unwanted CPR and intubation have achieved notoriety, but registries of legal cases⁶ probably underestimate the frequency of this harm. In a study of incorrect code status orders at Canadian hospitals, 35% of 308 patients with limited care preferences had full code orders in the chart.⁷ It is unclear how many of these expressed preferences also had legal documents available. There was considerable variability among hospitals, suggesting that local practices and culture were important factors.

Spot audits of 121 of our own patient charts (median age 77 years) on oncology, geriatrics, and cardiac units at our institution found 36 (30%) with AD/POLST that clearly limited life-sustaining treatments. Of these, 14 (39%) had discrepant full code orders. A review of these discrepant orders showed no medical documentation to indicate that the discrepancy was purposeful.

A root cause analysis (RCA) of cases of unwanted resuscitation, including interviews with involved nurses, medical staff, and operating room, hospitalist, and medical informatics leadership, revealed several types of error, both human and system. These pitfalls are probably common to several hospitals, and the solutions developed may be helpful as well (Table).

Haste leads to poor communication with the patient and family. Emergency departments and admitting services can be hectic. Clinicians facing time and acuity pressure may give short shrift to the essential activity of validating patient choices, regardless of whether an AD or POLST is available. Poor communication was the major factor allowing for discrepancy in the Canadian study.⁷ Avoiding prognostic frankness is a well-known coping strategy for both clinicians and patients^8,9 but in all these cases, that obstacle had been overcome earlier in the clinical course of disease, leaving inattention or haste as the most likely culprit.

“It is not our hospital culture to surveille for code status discrepancies, discuss appropriateness on rounds or at sign out.”

In all reviewed cases of unwanted resuscitation, numerous admitting or attending physicians failed to discuss LST meaningfully despite clinical scenarios that were associated with poor prognosis and should have provoked discussion about medical ineffectiveness. The admitting hospitalist in case 2 stated later that she had listed code choices for the patient who chose full code despite having a POLST stating otherwise. However, that discussion was not in depth, not reviewed for match to her POLST, and not documented.

Moreover, all the cases of AD/POLST and code status discrepancy were on nursing units with daily multidisciplinary rounds and where there had been twice-daily nurse-to-nurse and medical staff–to–medical staff sign out. Queries about code status appropriateness and checks for discrepant AD/POLST and code orders were not standard work. Thus, the medical error was perpetuated.

Analysis of cases of unwanted intubation in postoperative cases indicated that contrary to guidelines,^4,5 careful code status review was not part of the preoperative checklist or presurgical discussion.

The EMR is a well-recognized source of potential medical error.^10,11 Clinicians may rely on the EMR for code status history or as a repository of relevant documents. These are important as a starting place for code status discussions, especially since patients and proxies often cannot accurately recall the existence of an AD/POLST or understand the options being presented.^9,12 In case 1, clinicians partially relied upon the erroneous historical code status already in the chart from two prior admissions. This is a dangerous practice since code status choices have several options and depend upon the clinical situation. In the case of paper AD/POLST documents, the EMR is set up poorly to help the medical team find relevant documents. Furthermore, the EMR clinical decision support capabilities do not interact with paper documents, so no assistance in pointing out discrepancies is available. In addition, the scanning process itself can be problematic since scanning of paper documents was not performed until after the patient was discharged, thus hiding the most up-to-date documents from the personnel even if they had sought them. Moreover, our scanning process had been labeling documents with the date of scanning and not the date of completion, making it difficult to find the “active” order.

Interviews with different clinicians revealed widespread knowledge deficits, including appreciation of the POLST as durable across different medical institutions, effective differences between POLST and AD, location of POLST/AD within the EMR, recommendations of professional society guidelines on suspending DNR for procedures, hospital policy on same, the need to check for updates in bedside paper documents, and whether family members can overrule patients’ stated wishes. Education tends to be the most common form of recommendation after RCA and may be the least efficacious in risk mitigation,¹³ but in this case, education reinforced by new EMR capabilities was an essential part of the solutions bundle (Table).

AD/POLST and similar tools are complex, and the choices are not binary. They are subject to change depending upon the medical context and the patient status and may be poorly understood by patients and clinicians.¹⁴ Accordingly, writing a goal-concordant code status order demands time and attention and as much nuanced medical judgment as any other medical problem faced by hospital-based clinicians. Though time-consuming, discussion with the patient or the surrogate should be considered as “standard work.” To facilitate this, a mandatory affirmative statement about review of LST choices was added to admission templates, procedural areas, and clinician sign outs (Table).

Unwanted, and therefore unwarranted, resuscitation violates autonomy and creates distress, anger, and distrust among patients and families. The distress extends also to frontline clinicians who are committed to “do no harm” in every other aspect of their professional lives.

Respecting and translating patients’ AD/POLST or similar tools into goal-concordant code status order is an essential professional commitment. Respect for patient safety and autonomy demands that we do it well, teach it well, and hold each other accountable.

Disclosures

The authors have nothing disclose.