Practice Management

The year 2020 has brought the COVID-19 pandemic and civil unrest and protests, which have resulted in unprecedented health care challenges to hospitals and clinics. The daunting prospect of a fall influenza season has hospital staff and administrators looking ahead to still greater challenges.

This year of crisis has put even greater emphasis on leadership in hospitals, as patients, clinicians, and staff look for direction in the face of uncertainty and stress. But hospital leaders often arrive at their positions unprepared for their roles, according to Leonard Marcus, PhD, director of the Program for Health Care Negotiation and Conflict Resolution at Harvard T.H. Chan School of Public Health, Boston.

“Many times what happens in medicine is that someone with the greatest technical skills or greatest clinical skills emerges to be leader of a department, or a group, or a hospital, without having really paid attention to how they can build their leadership skills,” Dr. Marcus said during the 2020 Society of Hospital Medicine Leadership Virtual Seminar, held online Sept. 16-17.

Over 2 days, Dr. Marcus discussed the complex environments faced by hospital leaders, and some of the tools and strategies that can be used to maintain calm, problem-solve, and chart a course ahead.

He emphasized that hospitals and medical systems are complex, nonlinear organizations, which could be swept up by change in the form of mergers, financial policies, patient surges due to local emergencies, or pandemics.

“Complexity has to be central to how you think about leadership. If you think you can control everything, that doesn’t work that well,” said Dr. Marcus.

Most think of leadership as hierarchical, with a boss on top and underlings below, though this is starting to change. Dr. Marcus suggested a different view. Instead of just “leading down” to those who report to them, leaders should consider “leading up” to their own bosses or oversight committees, and across to other departments or even beyond to interlinked organizations such as nursing homes.

“Being able to build that connectivity not only within your hospital, but beyond your hospital, lets you see the chain that goes through the experience of any patient. You are looking at the problem from a much wider lens. We call this meta-leadership,” Dr. Marcus said.

A key focus of meta-leadership is to create a culture where individuals are working together to help one another succeed. Leadership in hospitals is often dominated by egos, with individual leaders battling one another in a win-lose effort, and this gets in the way of incorporating different perspectives into problem-solving.

Dr. Marcus used an example from previous seminars in which he instructed participants to arm wrestle the person sitting next to them. The goal was to attain as many pins as possible in 30 seconds. About half would fight as hard as they could, and achieve a few victories. The other half worked cooperatively, letting one person win, then the other, so that they could have 30 or 40 wins each. Dr. Marcus told the story of a young nurse who was paired up with a much stronger surgeon. She let him win twice, and when he asked her why she wasn’t resisting, she took his arm and placed it in a winning position, then a losing position, and then a winning position again, and he instantly understood that the cooperative approach could be more effective. Why didn’t she just tell him? She told Dr. Marcus that she knew he wouldn’t take instruction, so she let him win and then demonstrated an alternative. “We nurses learned how to do that a long time ago,” she told Dr. Marcus.

The idea is collaborative problem-solving. “How do you orient people looking to you for leadership so that we’re in this together and we can accomplish a whole lot more in 30 seconds if we’re working together instead of always battling one another? If we’re always battling one another, we’re putting all of our effort into the contest,” said Dr. Marcus. This sort of approach is all the more important when facing the complexity experienced by hospital systems, especially during crises such as COVID-19.

A critical element of meta-leadership is emotional intelligence, which includes elements such as self-awareness, self-regulation, empathy, determining motivation of yourself and others, and the social skills to portray yourself as caring, open, and interested.

Emotional intelligence also can help recognize when you’ve entered survival mode in reaction to a crisis or incident, or something as simple as losing your car keys – what Dr. Marcus terms “going to the basement.” Responses revolve around freeze, fight, or flight. It’s helpful in the wake of a car accident, but not when trying to make managerial decisions or respond to a complex situation. It’s vital for leaders to quickly get themselves out of the basement, said Dr. Marcus, and that they help other members of the team get out as well.

He recommended protocols designed in advance, both to recognize when you’re in the basement, and to lift yourself out. Dr. Marcus uses a trigger script, telling himself “I can do this,” and then when he’s working with other people, “we can do this.” He also speaks slowly, measuring every word. Whatever you do, “it has to be a pivot you do to get yourself out of the basement,” he said. It can be helpful to predict the kinds of situations that send you “to the basement” to help recognize it when it has happened.

It’s very important not to lead, negotiate, or make important decisions while in the basement, according to Dr. Marcus. If one thinks about some of the things they’ve said to others while under duress, they are often some of the statements they regret most.
 

Practical leadership skills

On the second day of the Leadership Seminar, Dr. Marcus moved his focus to using leadership skills and techniques. One important technique is to incorporate multiple perspectives. He gave the example of an opaque cube with a cone inside it, with a window on the side and one on top. Viewers from the side see the cone in profile, and see it as a triangle. Viewers from the top see an aerial perspective that looks like the circular base of the cone. The two groups could argue about what’s inside the cube, but they can only identify the object if they work together.

“When dealing with complex reality, you oftentimes find there are different people with different perspectives on a problem. They may have different experiences of what the problem is, and what often happens is that people get into an adversarial fight. Looking at the problem from different perspectives actually allows a much richer and more comprehensive view,” said Dr. Marcus.

The metaphor comes from a study of the tragic events at the Twin Towers in Manhattan on Sept. 11, 2001. The New York Fire Department had a command center at the base of the building, while the police had a helicopter flying around the buildings. The helicopter could see the steel girders beginning to melt and predicted a collapse, and therefore ordered their personnel out of the buildings. But they were unable to convey that information to the firefighters, who continued to send personnel into the buildings. In all, 343 firefighters lost their lives. The police force lost 32.

To best understand a problem, a key element is the “unknown knowns.” That is, information that is available, that someone has, but is unknown to you. It takes some imagination to conceive of what “unknown knowns” might be out there, but it’s worth the effort to identify possible knowledge sources. It’s vital to seek out this information, because a common leadership mistake is to assume you know something when you really don’t.

“In many ways what you’re doing is looking for obstacles. It could be you don’t have access to the information, that it’s beyond some sort of curtain you need to overcome, or it could be people in your own department who have the information and they’re not sharing it with you,” Dr. Marcus said.

He outlined a tool called the POP-DOC loop, which is a 6-step exercise designed to analyze problems and implement solutions. Step 1 is Perceiving the situation, determining knowns and unknowns, and incorporating multiple perspectives, emotions, and politics. Step 2 is to Orient oneself: examine patterns and how they may replicate themselves as long as conditions don’t change. For example, during COVID-19, physicians have begun to learn how the virus transmits and how it affects the immune system. Step 3, based on those patterns is to make Predictions. With COVID-19, it’s predictable that people who assemble without wearing masks are vulnerable to transmission. Step 4 is to use the predictions to begin to make Decisions. Step 5 is to begin Operationalizing those decisions, and step 6 is to Communicate those decisions effectively.

Dr. Marcus emphasized that POP-DOC is not a one-time exercise. Once decisions have been made and implemented, if they aren’t having the planned effect, it’s important to incorporate the results of those actions and start right back at the beginning of the POP-DOC loop.

“The POP side of the loop is perceiving, analysis. You get out of the basement and understand the situation that surrounds you. On the DOC side, you lead down, lead up, lead across and lead beyond. You’re bringing people into the action to get things done,” Dr. Marcus said.

Another tool Dr. Marcus described, aimed at problem-solving and negotiation, is the “Walk in the Woods.” The idea is to bring two parties together to help each other succeed. The first step is Self-Interest, where both parties articulate their objectives, perspectives, and fears. The second step, Enlarged Interests, requires each party to list their points of agreement, and only then should they focus on and list their points of disagreement. During conflict, people tend to focus on their disagreements. The parties often find that they agree on more than they realize, and this can frame the disagreements as more manageable. The third step, Enlightened Interest, is a free thinking period where both parties come up with potential solutions that had not been previously considered. In step 4, Aligned Interests, the parties discuss some of those ideas that can be explored further.

The Walk in the Woods is applicable to a wide range of situations, and negotiation is central to being a leader. “Being a clinician is all about negotiating – with patients, family members, with other clinicians, with the institution,” Dr. Marcus said. “We all want the patient to have the best possible care, and in the course of those conversations if we can better understand people, have empathy, and if there are new ideas or ways we can individualize our care, let’s do it, and then at the end of the day combine our motivations so that we’re providing the best possible care.”

In the end, meta-leadership is about creating a culture where individuals strive to help each other succeed, said Dr. Marcus. “That’s the essence: involving people, making them part of the solution, and if it’s a solution they’ve created together, everyone wants to make that solution a success.”

For more information, see the book “You’re It,” coauthored by Dr. Marcus, and available on Amazon for $16.99 in hardback, or $3.99 in Kindle format.

The year 2020 has brought the COVID-19 pandemic and civil unrest and protests, which have resulted in unprecedented health care challenges to hospitals and clinics. The daunting prospect of a fall influenza season has hospital staff and administrators looking ahead to still greater challenges.

This year of crisis has put even greater emphasis on leadership in hospitals, as patients, clinicians, and staff look for direction in the face of uncertainty and stress. But hospital leaders often arrive at their positions unprepared for their roles, according to Leonard Marcus, PhD, director of the Program for Health Care Negotiation and Conflict Resolution at Harvard T.H. Chan School of Public Health, Boston.

“Many times what happens in medicine is that someone with the greatest technical skills or greatest clinical skills emerges to be leader of a department, or a group, or a hospital, without having really paid attention to how they can build their leadership skills,” Dr. Marcus said during the 2020 Society of Hospital Medicine Leadership Virtual Seminar, held online Sept. 16-17.

Over 2 days, Dr. Marcus discussed the complex environments faced by hospital leaders, and some of the tools and strategies that can be used to maintain calm, problem-solve, and chart a course ahead.

He emphasized that hospitals and medical systems are complex, nonlinear organizations, which could be swept up by change in the form of mergers, financial policies, patient surges due to local emergencies, or pandemics.

“Complexity has to be central to how you think about leadership. If you think you can control everything, that doesn’t work that well,” said Dr. Marcus.

Most think of leadership as hierarchical, with a boss on top and underlings below, though this is starting to change. Dr. Marcus suggested a different view. Instead of just “leading down” to those who report to them, leaders should consider “leading up” to their own bosses or oversight committees, and across to other departments or even beyond to interlinked organizations such as nursing homes.

“Being able to build that connectivity not only within your hospital, but beyond your hospital, lets you see the chain that goes through the experience of any patient. You are looking at the problem from a much wider lens. We call this meta-leadership,” Dr. Marcus said.

A key focus of meta-leadership is to create a culture where individuals are working together to help one another succeed. Leadership in hospitals is often dominated by egos, with individual leaders battling one another in a win-lose effort, and this gets in the way of incorporating different perspectives into problem-solving.

Dr. Marcus used an example from previous seminars in which he instructed participants to arm wrestle the person sitting next to them. The goal was to attain as many pins as possible in 30 seconds. About half would fight as hard as they could, and achieve a few victories. The other half worked cooperatively, letting one person win, then the other, so that they could have 30 or 40 wins each. Dr. Marcus told the story of a young nurse who was paired up with a much stronger surgeon. She let him win twice, and when he asked her why she wasn’t resisting, she took his arm and placed it in a winning position, then a losing position, and then a winning position again, and he instantly understood that the cooperative approach could be more effective. Why didn’t she just tell him? She told Dr. Marcus that she knew he wouldn’t take instruction, so she let him win and then demonstrated an alternative. “We nurses learned how to do that a long time ago,” she told Dr. Marcus.

The idea is collaborative problem-solving. “How do you orient people looking to you for leadership so that we’re in this together and we can accomplish a whole lot more in 30 seconds if we’re working together instead of always battling one another? If we’re always battling one another, we’re putting all of our effort into the contest,” said Dr. Marcus. This sort of approach is all the more important when facing the complexity experienced by hospital systems, especially during crises such as COVID-19.

A critical element of meta-leadership is emotional intelligence, which includes elements such as self-awareness, self-regulation, empathy, determining motivation of yourself and others, and the social skills to portray yourself as caring, open, and interested.

Emotional intelligence also can help recognize when you’ve entered survival mode in reaction to a crisis or incident, or something as simple as losing your car keys – what Dr. Marcus terms “going to the basement.” Responses revolve around freeze, fight, or flight. It’s helpful in the wake of a car accident, but not when trying to make managerial decisions or respond to a complex situation. It’s vital for leaders to quickly get themselves out of the basement, said Dr. Marcus, and that they help other members of the team get out as well.

He recommended protocols designed in advance, both to recognize when you’re in the basement, and to lift yourself out. Dr. Marcus uses a trigger script, telling himself “I can do this,” and then when he’s working with other people, “we can do this.” He also speaks slowly, measuring every word. Whatever you do, “it has to be a pivot you do to get yourself out of the basement,” he said. It can be helpful to predict the kinds of situations that send you “to the basement” to help recognize it when it has happened.

It’s very important not to lead, negotiate, or make important decisions while in the basement, according to Dr. Marcus. If one thinks about some of the things they’ve said to others while under duress, they are often some of the statements they regret most.
 

Practical leadership skills

On the second day of the Leadership Seminar, Dr. Marcus moved his focus to using leadership skills and techniques. One important technique is to incorporate multiple perspectives. He gave the example of an opaque cube with a cone inside it, with a window on the side and one on top. Viewers from the side see the cone in profile, and see it as a triangle. Viewers from the top see an aerial perspective that looks like the circular base of the cone. The two groups could argue about what’s inside the cube, but they can only identify the object if they work together.

“When dealing with complex reality, you oftentimes find there are different people with different perspectives on a problem. They may have different experiences of what the problem is, and what often happens is that people get into an adversarial fight. Looking at the problem from different perspectives actually allows a much richer and more comprehensive view,” said Dr. Marcus.

The metaphor comes from a study of the tragic events at the Twin Towers in Manhattan on Sept. 11, 2001. The New York Fire Department had a command center at the base of the building, while the police had a helicopter flying around the buildings. The helicopter could see the steel girders beginning to melt and predicted a collapse, and therefore ordered their personnel out of the buildings. But they were unable to convey that information to the firefighters, who continued to send personnel into the buildings. In all, 343 firefighters lost their lives. The police force lost 32.

To best understand a problem, a key element is the “unknown knowns.” That is, information that is available, that someone has, but is unknown to you. It takes some imagination to conceive of what “unknown knowns” might be out there, but it’s worth the effort to identify possible knowledge sources. It’s vital to seek out this information, because a common leadership mistake is to assume you know something when you really don’t.

“In many ways what you’re doing is looking for obstacles. It could be you don’t have access to the information, that it’s beyond some sort of curtain you need to overcome, or it could be people in your own department who have the information and they’re not sharing it with you,” Dr. Marcus said.

He outlined a tool called the POP-DOC loop, which is a 6-step exercise designed to analyze problems and implement solutions. Step 1 is Perceiving the situation, determining knowns and unknowns, and incorporating multiple perspectives, emotions, and politics. Step 2 is to Orient oneself: examine patterns and how they may replicate themselves as long as conditions don’t change. For example, during COVID-19, physicians have begun to learn how the virus transmits and how it affects the immune system. Step 3, based on those patterns is to make Predictions. With COVID-19, it’s predictable that people who assemble without wearing masks are vulnerable to transmission. Step 4 is to use the predictions to begin to make Decisions. Step 5 is to begin Operationalizing those decisions, and step 6 is to Communicate those decisions effectively.

Dr. Marcus emphasized that POP-DOC is not a one-time exercise. Once decisions have been made and implemented, if they aren’t having the planned effect, it’s important to incorporate the results of those actions and start right back at the beginning of the POP-DOC loop.

“The POP side of the loop is perceiving, analysis. You get out of the basement and understand the situation that surrounds you. On the DOC side, you lead down, lead up, lead across and lead beyond. You’re bringing people into the action to get things done,” Dr. Marcus said.

Another tool Dr. Marcus described, aimed at problem-solving and negotiation, is the “Walk in the Woods.” The idea is to bring two parties together to help each other succeed. The first step is Self-Interest, where both parties articulate their objectives, perspectives, and fears. The second step, Enlarged Interests, requires each party to list their points of agreement, and only then should they focus on and list their points of disagreement. During conflict, people tend to focus on their disagreements. The parties often find that they agree on more than they realize, and this can frame the disagreements as more manageable. The third step, Enlightened Interest, is a free thinking period where both parties come up with potential solutions that had not been previously considered. In step 4, Aligned Interests, the parties discuss some of those ideas that can be explored further.

The Walk in the Woods is applicable to a wide range of situations, and negotiation is central to being a leader. “Being a clinician is all about negotiating – with patients, family members, with other clinicians, with the institution,” Dr. Marcus said. “We all want the patient to have the best possible care, and in the course of those conversations if we can better understand people, have empathy, and if there are new ideas or ways we can individualize our care, let’s do it, and then at the end of the day combine our motivations so that we’re providing the best possible care.”

In the end, meta-leadership is about creating a culture where individuals strive to help each other succeed, said Dr. Marcus. “That’s the essence: involving people, making them part of the solution, and if it’s a solution they’ve created together, everyone wants to make that solution a success.”

For more information, see the book “You’re It,” coauthored by Dr. Marcus, and available on Amazon for $16.99 in hardback, or $3.99 in Kindle format.

The year 2020 has brought the COVID-19 pandemic and civil unrest and protests, which have resulted in unprecedented health care challenges to hospitals and clinics. The daunting prospect of a fall influenza season has hospital staff and administrators looking ahead to still greater challenges.

This year of crisis has put even greater emphasis on leadership in hospitals, as patients, clinicians, and staff look for direction in the face of uncertainty and stress. But hospital leaders often arrive at their positions unprepared for their roles, according to Leonard Marcus, PhD, director of the Program for Health Care Negotiation and Conflict Resolution at Harvard T.H. Chan School of Public Health, Boston.

“Many times what happens in medicine is that someone with the greatest technical skills or greatest clinical skills emerges to be leader of a department, or a group, or a hospital, without having really paid attention to how they can build their leadership skills,” Dr. Marcus said during the 2020 Society of Hospital Medicine Leadership Virtual Seminar, held online Sept. 16-17.

Over 2 days, Dr. Marcus discussed the complex environments faced by hospital leaders, and some of the tools and strategies that can be used to maintain calm, problem-solve, and chart a course ahead.

He emphasized that hospitals and medical systems are complex, nonlinear organizations, which could be swept up by change in the form of mergers, financial policies, patient surges due to local emergencies, or pandemics.

“Complexity has to be central to how you think about leadership. If you think you can control everything, that doesn’t work that well,” said Dr. Marcus.

Most think of leadership as hierarchical, with a boss on top and underlings below, though this is starting to change. Dr. Marcus suggested a different view. Instead of just “leading down” to those who report to them, leaders should consider “leading up” to their own bosses or oversight committees, and across to other departments or even beyond to interlinked organizations such as nursing homes.

“Being able to build that connectivity not only within your hospital, but beyond your hospital, lets you see the chain that goes through the experience of any patient. You are looking at the problem from a much wider lens. We call this meta-leadership,” Dr. Marcus said.

A key focus of meta-leadership is to create a culture where individuals are working together to help one another succeed. Leadership in hospitals is often dominated by egos, with individual leaders battling one another in a win-lose effort, and this gets in the way of incorporating different perspectives into problem-solving.

Dr. Marcus used an example from previous seminars in which he instructed participants to arm wrestle the person sitting next to them. The goal was to attain as many pins as possible in 30 seconds. About half would fight as hard as they could, and achieve a few victories. The other half worked cooperatively, letting one person win, then the other, so that they could have 30 or 40 wins each. Dr. Marcus told the story of a young nurse who was paired up with a much stronger surgeon. She let him win twice, and when he asked her why she wasn’t resisting, she took his arm and placed it in a winning position, then a losing position, and then a winning position again, and he instantly understood that the cooperative approach could be more effective. Why didn’t she just tell him? She told Dr. Marcus that she knew he wouldn’t take instruction, so she let him win and then demonstrated an alternative. “We nurses learned how to do that a long time ago,” she told Dr. Marcus.

The idea is collaborative problem-solving. “How do you orient people looking to you for leadership so that we’re in this together and we can accomplish a whole lot more in 30 seconds if we’re working together instead of always battling one another? If we’re always battling one another, we’re putting all of our effort into the contest,” said Dr. Marcus. This sort of approach is all the more important when facing the complexity experienced by hospital systems, especially during crises such as COVID-19.

A critical element of meta-leadership is emotional intelligence, which includes elements such as self-awareness, self-regulation, empathy, determining motivation of yourself and others, and the social skills to portray yourself as caring, open, and interested.

Emotional intelligence also can help recognize when you’ve entered survival mode in reaction to a crisis or incident, or something as simple as losing your car keys – what Dr. Marcus terms “going to the basement.” Responses revolve around freeze, fight, or flight. It’s helpful in the wake of a car accident, but not when trying to make managerial decisions or respond to a complex situation. It’s vital for leaders to quickly get themselves out of the basement, said Dr. Marcus, and that they help other members of the team get out as well.

He recommended protocols designed in advance, both to recognize when you’re in the basement, and to lift yourself out. Dr. Marcus uses a trigger script, telling himself “I can do this,” and then when he’s working with other people, “we can do this.” He also speaks slowly, measuring every word. Whatever you do, “it has to be a pivot you do to get yourself out of the basement,” he said. It can be helpful to predict the kinds of situations that send you “to the basement” to help recognize it when it has happened.

It’s very important not to lead, negotiate, or make important decisions while in the basement, according to Dr. Marcus. If one thinks about some of the things they’ve said to others while under duress, they are often some of the statements they regret most.
 

Practical leadership skills

On the second day of the Leadership Seminar, Dr. Marcus moved his focus to using leadership skills and techniques. One important technique is to incorporate multiple perspectives. He gave the example of an opaque cube with a cone inside it, with a window on the side and one on top. Viewers from the side see the cone in profile, and see it as a triangle. Viewers from the top see an aerial perspective that looks like the circular base of the cone. The two groups could argue about what’s inside the cube, but they can only identify the object if they work together.

“When dealing with complex reality, you oftentimes find there are different people with different perspectives on a problem. They may have different experiences of what the problem is, and what often happens is that people get into an adversarial fight. Looking at the problem from different perspectives actually allows a much richer and more comprehensive view,” said Dr. Marcus.

The metaphor comes from a study of the tragic events at the Twin Towers in Manhattan on Sept. 11, 2001. The New York Fire Department had a command center at the base of the building, while the police had a helicopter flying around the buildings. The helicopter could see the steel girders beginning to melt and predicted a collapse, and therefore ordered their personnel out of the buildings. But they were unable to convey that information to the firefighters, who continued to send personnel into the buildings. In all, 343 firefighters lost their lives. The police force lost 32.

To best understand a problem, a key element is the “unknown knowns.” That is, information that is available, that someone has, but is unknown to you. It takes some imagination to conceive of what “unknown knowns” might be out there, but it’s worth the effort to identify possible knowledge sources. It’s vital to seek out this information, because a common leadership mistake is to assume you know something when you really don’t.

“In many ways what you’re doing is looking for obstacles. It could be you don’t have access to the information, that it’s beyond some sort of curtain you need to overcome, or it could be people in your own department who have the information and they’re not sharing it with you,” Dr. Marcus said.

He outlined a tool called the POP-DOC loop, which is a 6-step exercise designed to analyze problems and implement solutions. Step 1 is Perceiving the situation, determining knowns and unknowns, and incorporating multiple perspectives, emotions, and politics. Step 2 is to Orient oneself: examine patterns and how they may replicate themselves as long as conditions don’t change. For example, during COVID-19, physicians have begun to learn how the virus transmits and how it affects the immune system. Step 3, based on those patterns is to make Predictions. With COVID-19, it’s predictable that people who assemble without wearing masks are vulnerable to transmission. Step 4 is to use the predictions to begin to make Decisions. Step 5 is to begin Operationalizing those decisions, and step 6 is to Communicate those decisions effectively.

Dr. Marcus emphasized that POP-DOC is not a one-time exercise. Once decisions have been made and implemented, if they aren’t having the planned effect, it’s important to incorporate the results of those actions and start right back at the beginning of the POP-DOC loop.

“The POP side of the loop is perceiving, analysis. You get out of the basement and understand the situation that surrounds you. On the DOC side, you lead down, lead up, lead across and lead beyond. You’re bringing people into the action to get things done,” Dr. Marcus said.

Another tool Dr. Marcus described, aimed at problem-solving and negotiation, is the “Walk in the Woods.” The idea is to bring two parties together to help each other succeed. The first step is Self-Interest, where both parties articulate their objectives, perspectives, and fears. The second step, Enlarged Interests, requires each party to list their points of agreement, and only then should they focus on and list their points of disagreement. During conflict, people tend to focus on their disagreements. The parties often find that they agree on more than they realize, and this can frame the disagreements as more manageable. The third step, Enlightened Interest, is a free thinking period where both parties come up with potential solutions that had not been previously considered. In step 4, Aligned Interests, the parties discuss some of those ideas that can be explored further.

The Walk in the Woods is applicable to a wide range of situations, and negotiation is central to being a leader. “Being a clinician is all about negotiating – with patients, family members, with other clinicians, with the institution,” Dr. Marcus said. “We all want the patient to have the best possible care, and in the course of those conversations if we can better understand people, have empathy, and if there are new ideas or ways we can individualize our care, let’s do it, and then at the end of the day combine our motivations so that we’re providing the best possible care.”

In the end, meta-leadership is about creating a culture where individuals strive to help each other succeed, said Dr. Marcus. “That’s the essence: involving people, making them part of the solution, and if it’s a solution they’ve created together, everyone wants to make that solution a success.”

For more information, see the book “You’re It,” coauthored by Dr. Marcus, and available on Amazon for $16.99 in hardback, or $3.99 in Kindle format.

We think of a patient’s recovery happening in multiple locations – in a hospital room or a rehabilitation facility, for example. But many clinicians may not consider the opportunity to aid healing that lies in the waiting room.

The waiting room is where a patient’s loved ones often are and they, sometimes more than anyone, can unlock the path to a patient’s quicker recovery. Friends and family can offer encouragement, as they have an existing bond of trust that can help if a patient needs reinforcement to take their medications or follow other health care advice. But if loved ones are going to help patients, they need help from clinicians. Beyond being potential allies, they are also hurting, experiencing worry or confusion in a world of medical jargon.

The coronavirus changes the relationship of patients and their loved ones, as patients are often isolated or limited in the number of visitors they are allowed to see. A smartphone replaces the smiling faces of friends and relatives at their bedside, and a text is a poor substitute for a hug.

The Hospitalist asked some experienced hospitalists for insight on how best to communicate with patients’ loved ones to improve outcomes for all, medically and emotionally.
 

Team approach

“Patients feel isolated, terrified, and vulnerable but still need an advocate in the hospital, so daily communication with a patient’s loved one is important to give a sense that the patient is looked after,” said Kari Esbensen, MD, PhD, a hospitalist and palliative care expert at Emory University Hospital Midtown, Atlanta.

Glenn Rosenbluth, MD, a pediatric hospitalist and director, quality and safety programs, at the University of California, San Francisco, Benioff Children’s Hospital, agreed. He said that the most important thing is to communicate, period.

“We fall into this pattern of ‘out of sight, out of mind,’ ” he said. “We need to take the extra step to find out who a patient’s loved ones are. If it is a clinical visit, ask the patient, or maybe get the information from a caseworker, or just pay attention to who is dropping in to see the patient. Having a second person available to jot down notes, or having a handy list of questions – it all helps the patient. We forget that sometimes it can seem like a whirlwind for the patient when they are hurting. We have to remember that a loved one is important to a patient’s care team and we need to include them, empower them, and show that we want to hear their voices.”

Dr. Esbensen said it is critical to start off on the right foot when communicating with a patient’s loved one, especially during the current pandemic.

“With COVID-19, the most important thing is to speak honestly, to say hope for the best but prepare for the worst-case scenario,” Dr. Esbensen said. “We’ve seen that conditions can shift dramatically in short periods of time. The loved one needs to have a sense of the positive and negative possibilities. Families tend to lack understanding of the changes in the patient that are caused by COVID-19. The patient can come out of the hospital debilitated, very different than when they entered the hospital, and we need to warn people close to them about this. Unrealistic expectations need to be guarded against if a patient’s loved ones are going to help.”

Perhaps the best form of communication with a patient’s loved ones is an often-forgotten skill: listening.

“Get an idea from the patient’s loved ones of what the issues are, as well as their idea of what they think of the disease and how it spreads,” Dr. Esbensen said. “Sometimes they are right on target but sometimes there are misinterpretations and we need to help them understand it better. It’s not a ‘one-size-fits-all’ speech that we should give, but try to say, ‘tell me what you think is going on, what you think you’ve heard, and what you’re worried about,’ and learn what is most important to the patient. Start on those terms and adapt; this way you can correct and address what makes them most fearful, which can be different for each loved one. For some, the concern could be that they have children or other vulnerable people in the house. Finding out these other issues is important.”

“A lot of people just want information and want to be helpful, but we also need to realize that, while we are caring for many patients, this one person is the patient they are focused on,” said Laura Nell Hodo, MD, a pediatric hospitalist at Kravis Children’s Hospital at Mount Sinai in New York. “Don’t rush, and if you know that a patient’s loved one needs more time, make sure it can be found – if not then, at least later on the phone. Fifteen to 20 minutes may be what’s needed, and you can’t shortchange them.”

Dr. Hodo said that a patient’s loved ones often do not realize it is possible to receive phone calls from hospitalists. “We need to remind them that they can get in touch with us. We have to remember how helpless they can feel and how they want to understand what is happening in the hospital.”

For medical adherence issues, sometimes it is best to communicate with the patient and loved one at the same time, Dr. Hodo advised. “Whether it’s for medication or postdischarge exercises, if they both receive the information together it can reinforce adherence. But you also need to remember that the patient may only want a loved one told about certain things, or possibly nothing at all. We need to make sure we understand the patient’s wishes, regardless of whether we think a person close to them can be an ally or not.”

Dr. Esbensen also noted that a loved one can give hospitalists important clues to the emotional components of a patient’s care.

“I remember a patient whose wife told me how he worked in a garage, how he was strong and did not want people to think he was a weak guy just because of what was happening to him,” Dr. Esbensen said. “I didn’t know that he felt he might be perceived in this way. I mentioned to him how I learned he was a good mechanic and he perked up and felt seen in a different light. These things make a difference.”

But when is the best time to speak with a patient’s loved ones? Since much communication is done via phone during the pandemic, there are different philosophies.

“We had a debate among colleagues to see how each of us did it,” Dr. Esbensen said. “Some try to call after each patient encounter, while they are outside the room and it’s fresh in their mind, but others find it better to make the call after their rounds, to give the person their full attention. Most of the time I try to do it that way.”

She noted that, in the current environment, a phone call may be better than a face-to-face conversation with patients’ loved ones.

“We’re covered in so much gear to protect us from the coronavirus that it can feel like a great distance exists between us and the person with whom we’re speaking,” she said. “It’s strange, but the phone can make the conversation seem more relaxed and may get people to open up more.”
 

Even when they leave

All the hospitalists affirmed that loved ones can make a big difference for the patient through all aspects of care. Long after a patient returns home, the support of loved ones can have a profound impact in speeding healing and improving long-term outcomes.

Dr. Esbensen said COVID-19 and other serious illnesses can leave a patient needing support, and maybe a “push” when feeling low keeps them from adhering to medical advice.

“It’s not just in the hospital but after discharge,” she said. “A person offering support can really help patients throughout their journey, and much success in recovering from illness occurs after the transition home. Having the support of that one person a patient trusts can be critical.”

Dr. Hodo believes that the coronavirus pandemic could forever change the way hospitalists communicate with patients and their loved ones.

“I work in pediatrics and we know serious medical decisions can’t be made without guardians or parents,” she said. “But in adult medicine doctors may not automatically ask the patient about calling someone for input on decision-making. With COVID, you cannot assume a patient is on their own, because there are protocols keeping people from physically being present in the patient’s room. My experience from working in adult coronavirus units is that the thinking about the loved ones’ role in patient care – and communication with them – might just change. … At least, I hope so.”
 

Quick takeaways for hospitalists

• Get beyond personal protective equipment. A conversation with a patient’s loved one might be easier to achieve via phone, without all the protective gear in the way.
• Encourage adherence. Speaking with patients and loved ones together may be more effective. They may reach agreement quicker on how best to adhere to medical advice.
• Loved ones offer clues. They might give you a better sense of a patient’s worries, or help you to connect better with those in your care.
• Be present. You have a long to-do list but do not let empathy fall off it, even if you feel overwhelmed.

We think of a patient’s recovery happening in multiple locations – in a hospital room or a rehabilitation facility, for example. But many clinicians may not consider the opportunity to aid healing that lies in the waiting room.

The waiting room is where a patient’s loved ones often are and they, sometimes more than anyone, can unlock the path to a patient’s quicker recovery. Friends and family can offer encouragement, as they have an existing bond of trust that can help if a patient needs reinforcement to take their medications or follow other health care advice. But if loved ones are going to help patients, they need help from clinicians. Beyond being potential allies, they are also hurting, experiencing worry or confusion in a world of medical jargon.

The coronavirus changes the relationship of patients and their loved ones, as patients are often isolated or limited in the number of visitors they are allowed to see. A smartphone replaces the smiling faces of friends and relatives at their bedside, and a text is a poor substitute for a hug.

The Hospitalist asked some experienced hospitalists for insight on how best to communicate with patients’ loved ones to improve outcomes for all, medically and emotionally.
 

Team approach

“Patients feel isolated, terrified, and vulnerable but still need an advocate in the hospital, so daily communication with a patient’s loved one is important to give a sense that the patient is looked after,” said Kari Esbensen, MD, PhD, a hospitalist and palliative care expert at Emory University Hospital Midtown, Atlanta.

Glenn Rosenbluth, MD, a pediatric hospitalist and director, quality and safety programs, at the University of California, San Francisco, Benioff Children’s Hospital, agreed. He said that the most important thing is to communicate, period.

“We fall into this pattern of ‘out of sight, out of mind,’ ” he said. “We need to take the extra step to find out who a patient’s loved ones are. If it is a clinical visit, ask the patient, or maybe get the information from a caseworker, or just pay attention to who is dropping in to see the patient. Having a second person available to jot down notes, or having a handy list of questions – it all helps the patient. We forget that sometimes it can seem like a whirlwind for the patient when they are hurting. We have to remember that a loved one is important to a patient’s care team and we need to include them, empower them, and show that we want to hear their voices.”

Dr. Esbensen said it is critical to start off on the right foot when communicating with a patient’s loved one, especially during the current pandemic.

“With COVID-19, the most important thing is to speak honestly, to say hope for the best but prepare for the worst-case scenario,” Dr. Esbensen said. “We’ve seen that conditions can shift dramatically in short periods of time. The loved one needs to have a sense of the positive and negative possibilities. Families tend to lack understanding of the changes in the patient that are caused by COVID-19. The patient can come out of the hospital debilitated, very different than when they entered the hospital, and we need to warn people close to them about this. Unrealistic expectations need to be guarded against if a patient’s loved ones are going to help.”

Perhaps the best form of communication with a patient’s loved ones is an often-forgotten skill: listening.

“Get an idea from the patient’s loved ones of what the issues are, as well as their idea of what they think of the disease and how it spreads,” Dr. Esbensen said. “Sometimes they are right on target but sometimes there are misinterpretations and we need to help them understand it better. It’s not a ‘one-size-fits-all’ speech that we should give, but try to say, ‘tell me what you think is going on, what you think you’ve heard, and what you’re worried about,’ and learn what is most important to the patient. Start on those terms and adapt; this way you can correct and address what makes them most fearful, which can be different for each loved one. For some, the concern could be that they have children or other vulnerable people in the house. Finding out these other issues is important.”

“A lot of people just want information and want to be helpful, but we also need to realize that, while we are caring for many patients, this one person is the patient they are focused on,” said Laura Nell Hodo, MD, a pediatric hospitalist at Kravis Children’s Hospital at Mount Sinai in New York. “Don’t rush, and if you know that a patient’s loved one needs more time, make sure it can be found – if not then, at least later on the phone. Fifteen to 20 minutes may be what’s needed, and you can’t shortchange them.”

Dr. Hodo said that a patient’s loved ones often do not realize it is possible to receive phone calls from hospitalists. “We need to remind them that they can get in touch with us. We have to remember how helpless they can feel and how they want to understand what is happening in the hospital.”

For medical adherence issues, sometimes it is best to communicate with the patient and loved one at the same time, Dr. Hodo advised. “Whether it’s for medication or postdischarge exercises, if they both receive the information together it can reinforce adherence. But you also need to remember that the patient may only want a loved one told about certain things, or possibly nothing at all. We need to make sure we understand the patient’s wishes, regardless of whether we think a person close to them can be an ally or not.”

Dr. Esbensen also noted that a loved one can give hospitalists important clues to the emotional components of a patient’s care.

“I remember a patient whose wife told me how he worked in a garage, how he was strong and did not want people to think he was a weak guy just because of what was happening to him,” Dr. Esbensen said. “I didn’t know that he felt he might be perceived in this way. I mentioned to him how I learned he was a good mechanic and he perked up and felt seen in a different light. These things make a difference.”

But when is the best time to speak with a patient’s loved ones? Since much communication is done via phone during the pandemic, there are different philosophies.

“We had a debate among colleagues to see how each of us did it,” Dr. Esbensen said. “Some try to call after each patient encounter, while they are outside the room and it’s fresh in their mind, but others find it better to make the call after their rounds, to give the person their full attention. Most of the time I try to do it that way.”

She noted that, in the current environment, a phone call may be better than a face-to-face conversation with patients’ loved ones.

“We’re covered in so much gear to protect us from the coronavirus that it can feel like a great distance exists between us and the person with whom we’re speaking,” she said. “It’s strange, but the phone can make the conversation seem more relaxed and may get people to open up more.”
 

Even when they leave

All the hospitalists affirmed that loved ones can make a big difference for the patient through all aspects of care. Long after a patient returns home, the support of loved ones can have a profound impact in speeding healing and improving long-term outcomes.

Dr. Esbensen said COVID-19 and other serious illnesses can leave a patient needing support, and maybe a “push” when feeling low keeps them from adhering to medical advice.

“It’s not just in the hospital but after discharge,” she said. “A person offering support can really help patients throughout their journey, and much success in recovering from illness occurs after the transition home. Having the support of that one person a patient trusts can be critical.”

Dr. Hodo believes that the coronavirus pandemic could forever change the way hospitalists communicate with patients and their loved ones.

“I work in pediatrics and we know serious medical decisions can’t be made without guardians or parents,” she said. “But in adult medicine doctors may not automatically ask the patient about calling someone for input on decision-making. With COVID, you cannot assume a patient is on their own, because there are protocols keeping people from physically being present in the patient’s room. My experience from working in adult coronavirus units is that the thinking about the loved ones’ role in patient care – and communication with them – might just change. … At least, I hope so.”
 

Quick takeaways for hospitalists

• Get beyond personal protective equipment. A conversation with a patient’s loved one might be easier to achieve via phone, without all the protective gear in the way.
• Encourage adherence. Speaking with patients and loved ones together may be more effective. They may reach agreement quicker on how best to adhere to medical advice.
• Loved ones offer clues. They might give you a better sense of a patient’s worries, or help you to connect better with those in your care.
• Be present. You have a long to-do list but do not let empathy fall off it, even if you feel overwhelmed.

We think of a patient’s recovery happening in multiple locations – in a hospital room or a rehabilitation facility, for example. But many clinicians may not consider the opportunity to aid healing that lies in the waiting room.

The waiting room is where a patient’s loved ones often are and they, sometimes more than anyone, can unlock the path to a patient’s quicker recovery. Friends and family can offer encouragement, as they have an existing bond of trust that can help if a patient needs reinforcement to take their medications or follow other health care advice. But if loved ones are going to help patients, they need help from clinicians. Beyond being potential allies, they are also hurting, experiencing worry or confusion in a world of medical jargon.

The coronavirus changes the relationship of patients and their loved ones, as patients are often isolated or limited in the number of visitors they are allowed to see. A smartphone replaces the smiling faces of friends and relatives at their bedside, and a text is a poor substitute for a hug.

The Hospitalist asked some experienced hospitalists for insight on how best to communicate with patients’ loved ones to improve outcomes for all, medically and emotionally.
 

Team approach

“Patients feel isolated, terrified, and vulnerable but still need an advocate in the hospital, so daily communication with a patient’s loved one is important to give a sense that the patient is looked after,” said Kari Esbensen, MD, PhD, a hospitalist and palliative care expert at Emory University Hospital Midtown, Atlanta.

Glenn Rosenbluth, MD, a pediatric hospitalist and director, quality and safety programs, at the University of California, San Francisco, Benioff Children’s Hospital, agreed. He said that the most important thing is to communicate, period.

“We fall into this pattern of ‘out of sight, out of mind,’ ” he said. “We need to take the extra step to find out who a patient’s loved ones are. If it is a clinical visit, ask the patient, or maybe get the information from a caseworker, or just pay attention to who is dropping in to see the patient. Having a second person available to jot down notes, or having a handy list of questions – it all helps the patient. We forget that sometimes it can seem like a whirlwind for the patient when they are hurting. We have to remember that a loved one is important to a patient’s care team and we need to include them, empower them, and show that we want to hear their voices.”

Dr. Esbensen said it is critical to start off on the right foot when communicating with a patient’s loved one, especially during the current pandemic.

“With COVID-19, the most important thing is to speak honestly, to say hope for the best but prepare for the worst-case scenario,” Dr. Esbensen said. “We’ve seen that conditions can shift dramatically in short periods of time. The loved one needs to have a sense of the positive and negative possibilities. Families tend to lack understanding of the changes in the patient that are caused by COVID-19. The patient can come out of the hospital debilitated, very different than when they entered the hospital, and we need to warn people close to them about this. Unrealistic expectations need to be guarded against if a patient’s loved ones are going to help.”

Perhaps the best form of communication with a patient’s loved ones is an often-forgotten skill: listening.

“Get an idea from the patient’s loved ones of what the issues are, as well as their idea of what they think of the disease and how it spreads,” Dr. Esbensen said. “Sometimes they are right on target but sometimes there are misinterpretations and we need to help them understand it better. It’s not a ‘one-size-fits-all’ speech that we should give, but try to say, ‘tell me what you think is going on, what you think you’ve heard, and what you’re worried about,’ and learn what is most important to the patient. Start on those terms and adapt; this way you can correct and address what makes them most fearful, which can be different for each loved one. For some, the concern could be that they have children or other vulnerable people in the house. Finding out these other issues is important.”

“A lot of people just want information and want to be helpful, but we also need to realize that, while we are caring for many patients, this one person is the patient they are focused on,” said Laura Nell Hodo, MD, a pediatric hospitalist at Kravis Children’s Hospital at Mount Sinai in New York. “Don’t rush, and if you know that a patient’s loved one needs more time, make sure it can be found – if not then, at least later on the phone. Fifteen to 20 minutes may be what’s needed, and you can’t shortchange them.”

Dr. Hodo said that a patient’s loved ones often do not realize it is possible to receive phone calls from hospitalists. “We need to remind them that they can get in touch with us. We have to remember how helpless they can feel and how they want to understand what is happening in the hospital.”

For medical adherence issues, sometimes it is best to communicate with the patient and loved one at the same time, Dr. Hodo advised. “Whether it’s for medication or postdischarge exercises, if they both receive the information together it can reinforce adherence. But you also need to remember that the patient may only want a loved one told about certain things, or possibly nothing at all. We need to make sure we understand the patient’s wishes, regardless of whether we think a person close to them can be an ally or not.”

Dr. Esbensen also noted that a loved one can give hospitalists important clues to the emotional components of a patient’s care.

“I remember a patient whose wife told me how he worked in a garage, how he was strong and did not want people to think he was a weak guy just because of what was happening to him,” Dr. Esbensen said. “I didn’t know that he felt he might be perceived in this way. I mentioned to him how I learned he was a good mechanic and he perked up and felt seen in a different light. These things make a difference.”

But when is the best time to speak with a patient’s loved ones? Since much communication is done via phone during the pandemic, there are different philosophies.

“We had a debate among colleagues to see how each of us did it,” Dr. Esbensen said. “Some try to call after each patient encounter, while they are outside the room and it’s fresh in their mind, but others find it better to make the call after their rounds, to give the person their full attention. Most of the time I try to do it that way.”

She noted that, in the current environment, a phone call may be better than a face-to-face conversation with patients’ loved ones.

“We’re covered in so much gear to protect us from the coronavirus that it can feel like a great distance exists between us and the person with whom we’re speaking,” she said. “It’s strange, but the phone can make the conversation seem more relaxed and may get people to open up more.”
 

Even when they leave

All the hospitalists affirmed that loved ones can make a big difference for the patient through all aspects of care. Long after a patient returns home, the support of loved ones can have a profound impact in speeding healing and improving long-term outcomes.

Dr. Esbensen said COVID-19 and other serious illnesses can leave a patient needing support, and maybe a “push” when feeling low keeps them from adhering to medical advice.

“It’s not just in the hospital but after discharge,” she said. “A person offering support can really help patients throughout their journey, and much success in recovering from illness occurs after the transition home. Having the support of that one person a patient trusts can be critical.”

Dr. Hodo believes that the coronavirus pandemic could forever change the way hospitalists communicate with patients and their loved ones.

“I work in pediatrics and we know serious medical decisions can’t be made without guardians or parents,” she said. “But in adult medicine doctors may not automatically ask the patient about calling someone for input on decision-making. With COVID, you cannot assume a patient is on their own, because there are protocols keeping people from physically being present in the patient’s room. My experience from working in adult coronavirus units is that the thinking about the loved ones’ role in patient care – and communication with them – might just change. … At least, I hope so.”
 

Quick takeaways for hospitalists

• Get beyond personal protective equipment. A conversation with a patient’s loved one might be easier to achieve via phone, without all the protective gear in the way.
• Encourage adherence. Speaking with patients and loved ones together may be more effective. They may reach agreement quicker on how best to adhere to medical advice.
• Loved ones offer clues. They might give you a better sense of a patient’s worries, or help you to connect better with those in your care.
• Be present. You have a long to-do list but do not let empathy fall off it, even if you feel overwhelmed.

Rural primary care doctors are facing a new set of obstacles to practicing in the COVID-19 pandemic. These include struggling with seeing patients virtually and treating patients who have politicized the virus. Additionally, the pandemic has exposed rural practices to greater financial difficulties.

Courtesy Dr. Jacqueline W. Fincher

Before the pandemic some rurally based primary care physicians were already working through big challenges, such as having few local medical colleagues to consult and working in small practices with lean budgets. In fact, data gathered by the National Rural Health Association showed that there are only 40 primary care physicians per 100,000 patients in rural regions, compared with 53 in urban areas – and the number of physicians overall is 13 per 10,000 in rural areas, compared with 31 in cities.

In the prepandemic world, for some doctors, the challenges were balanced by the benefits of practicing in these sparsely populated communities with scenic, low-traffic roads. Some perks of practicing in rural areas touted by doctors included having a fast commute, being able to swim in a lake near the office before work, having a low cost of living, and feeling like they are making a difference in their communities as they treat generations of the families they see around town.

But today, new hurdles to practicing medicine in rural America created by the COVID-19 pandemic have caused the hardships to feel heavier than the joys at times for some physicians interviewed by MDedge.

Many independent rural practices in need of assistance were not able to get much from the federal Provider Relief Funds, said John M. Westfall, MD, who is director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, in an interview.

“Rural primary care doctors function independently or in smaller critical access hospitals and community health centers,” said Dr. Westfall, who previously practiced family medicine in a small town in Colorado. “Many of these have much less financial reserves so are at risk of cutbacks and closure.”

Jacqueline W. Fincher, MD, an internist based in a tiny Georgia community along the highway between Atlanta and Augusta, said her small practice works on really thin margins and doesn’t have much cushion. At the beginning of the pandemic, all visits were down, and her practice operated at a loss. To help, Dr. Fincher and her colleagues applied for funding from the Small Business Administration’s Paycheck Protection Program (PPP) through the CARES Act.

“COVID-19 has had a tremendous impact especially on primary care practices. We live and die by volume. … Our volume in mid-March to mid-May really dropped dramatically,” explained Dr. Fincher, who is also president of the American College of Physicians. “The PPP sustained us for 2 months, enabling us to pay our staff and to remain open and get us up and running on telehealth.”
 

Starting up telemedicine

Experiencing spotty or no access to broadband Internet is nothing new to rural physicians, but having this problem interfere with their ability to provide care to patients is.

As much of the American health system rapidly embraced telehealth during the pandemic, obtaining access to high-speed Internet has been a major challenge for rural patients, noted Dr. Westfall.

“Some practices were able to quickly adopt some telehealth capacity with phone and video. Changes in payment for telehealth helped. But in some rural communities there was not adequate Internet bandwidth for quality video connections. And some patients did not have the means for high-speed video connections,” Dr. Westfall said.

Indeed, according to a 2019 Pew Research Center survey, 63% of rural Americans say they can access the Internet through a broadband connection at home, compared with 75% and 79% in suburban and urban areas, respectively.

G&P Productions

In the Appalachian town of Zanesville, Ohio, for example, family physician Shelly L. Dunmyer, MD, and her colleagues discovered that many patients don’t have Internet access at home. Dr. Fincher has to go to the office to conduct telehealth visits because her own Internet access at home is unpredictable. As for patients, it may take 15 minutes for them to work out technical glitches and find good Internet reception, said Dr. Fincher. For internist Y. Ki Shin, MD, who practices in the coastal town of Montesano in Washington state, about 25% of his practice’s telehealth visits must be conducted by phone because of limitations on video, such as lack of high-speed access.

But telephone visits are often insufficient replacements for appointments via video, according to several rural physicians interviewed for this piece.

“Telehealth can be frustrating at times due to connectivity issues which can be difficult at times in the rural areas,” said Dr. Fincher. “In order for telehealth to be reasonably helpful to patients and physicians to care for people with chronic problems, the patients must have things like blood pressure monitors, glucometers, and scales to address problems like hypertension, diabetes myelitis, and congestive heart failure.”

“If you have the audio and video and the data from these devices, you’re good. If you don’t have these data, and/or don’t have the video you just can’t provide good care,” she explained.

G&P Productions

Dr. Dunmyer and her colleagues at Medical Home Primary Care Center in Zanesville, Ohio, found a way to get around the problem of patients not being able to access Internet to participate in video visits from their homes. This involved having her patients drive into her practice’s parking lot to participate in modified telehealth visits. Staffers gave iPads to patients in their cars, and Dr. Dunmyer conducted visits from her office, about 50 yards away.

“We were even doing Medicare wellness visits: Instead of asking them to get up and move around the room, we would sit at the window and wave at them, ask them to get out, walk around the car. We were able to check mobility and all kinds of things that we’d normally do in the office,” Dr. Dunmyer explained in an interview.

The family physician noted that her practice is now conducting fewer parking lot visits since her office is allowing in-person appointments, but that they’re still an option for her patients.
 

Treating political adversaries

Some rural physicians have experienced strained relationships with patients for reasons other than technology – stark differences in opinion over the pandemic itself. Certain patients are following President Trump’s lead and questioning everything from the pandemic death toll to preventive measures recommended by scientists and medical experts, physicians interviewed by MDedge said.

Patients everywhere share these viewpoints, of course, but research and election results confirm that rural areas are more receptive to conservative viewpoints. In 2018, a Pew Research Center survey reported that rural and urban areas are “becoming more polarized politically,” and “rural areas tend to have a higher concentration of Republicans and Republican-leaning independents.” For example, 40% of rural respondents reported “very warm” or “somewhat warm” feelings toward Donald Trump, compared with just 19% in urban areas.

Dr. Shin has struggled to cope with patients who want to argue about pandemic safety precautions like wearing masks and seem to question whether systemic racism exists.

“We are seeing a lot more people who feel that this pandemic is not real, that it’s a political and not-true infection,” he said in an interview. “We’ve had patients who were angry at us because we made them wear masks, and some were demanding hydroxychloroquine and wanted to have an argument because we’re not going to prescribe it for them.”

In one situation, which he found especially disturbing, Dr. Shin had to leave the exam room because a patient wouldn’t stop challenging him regarding the pandemic. Things have gotten so bad that Dr. Shin has even questioned whether he wants to continue his long career in his small town because of local political attitudes such as opposition to mask-wearing and social distancing.

“Mr. Trump’s misinformation on this pandemic made my job much more difficult. As a minority, I feel less safe in my community than ever,” said Dr. Shin, who described himself as Asian American.

Despite these new stressors, Dr. Shin has experienced some joyful moments while practicing medicine in the pandemic.

Courtesy Dr. Clara Shin

He said a recent home visit to a patient who had been hospitalized for over 3 months and nearly died helped him put political disputes with his patients into perspective.

“He was discharged home but is bedbound. He had gangrene on his toes, and I could not fully examine him using video,” Dr. Shin recalled. “It was tricky to find the house, but a very large Trump sign was very helpful in locating it. It was a good visit: He was happy to see me, and I was happy to see that he was doing okay at home.”

“I need to remind myself that supporting Mr. Trump does not always mean that my patient supports Mr. Trump’s view on the pandemic and the race issues in our country,” Dr. Shin added.

The Washington-based internist said he also tells himself that, even if his patients refuse to follow his strong advice regarding pandemic precautions, it does not mean he has failed as a doctor.

“I need to continue to educate patients about the dangers of COVID infection but cannot be angry if they don’t choose to follow my recommendations,” he noted.

Dr. Fincher says her close connection with patients has allowed her to smooth over politically charged claims about the pandemic in the town of Thomson, Georgia, with a population 6,800.

“I have a sense that, even though we may differ in our understanding of some basic facts, they appreciate what I say since we have a long-term relationship built on trust,” she said. This kind of trust, Dr. Fincher suggested, may be more common than in urban areas where there’s a larger supply of physicians, and patients don’t see the same doctors for long periods of time.

“It’s more meaningful when it comes from me, rather than doctors who are [new to patients] every year when their employer changes their insurance,” she noted.

Rural primary care doctors are facing a new set of obstacles to practicing in the COVID-19 pandemic. These include struggling with seeing patients virtually and treating patients who have politicized the virus. Additionally, the pandemic has exposed rural practices to greater financial difficulties.

Courtesy Dr. Jacqueline W. Fincher

Before the pandemic some rurally based primary care physicians were already working through big challenges, such as having few local medical colleagues to consult and working in small practices with lean budgets. In fact, data gathered by the National Rural Health Association showed that there are only 40 primary care physicians per 100,000 patients in rural regions, compared with 53 in urban areas – and the number of physicians overall is 13 per 10,000 in rural areas, compared with 31 in cities.

In the prepandemic world, for some doctors, the challenges were balanced by the benefits of practicing in these sparsely populated communities with scenic, low-traffic roads. Some perks of practicing in rural areas touted by doctors included having a fast commute, being able to swim in a lake near the office before work, having a low cost of living, and feeling like they are making a difference in their communities as they treat generations of the families they see around town.

But today, new hurdles to practicing medicine in rural America created by the COVID-19 pandemic have caused the hardships to feel heavier than the joys at times for some physicians interviewed by MDedge.

Many independent rural practices in need of assistance were not able to get much from the federal Provider Relief Funds, said John M. Westfall, MD, who is director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, in an interview.

“Rural primary care doctors function independently or in smaller critical access hospitals and community health centers,” said Dr. Westfall, who previously practiced family medicine in a small town in Colorado. “Many of these have much less financial reserves so are at risk of cutbacks and closure.”

Jacqueline W. Fincher, MD, an internist based in a tiny Georgia community along the highway between Atlanta and Augusta, said her small practice works on really thin margins and doesn’t have much cushion. At the beginning of the pandemic, all visits were down, and her practice operated at a loss. To help, Dr. Fincher and her colleagues applied for funding from the Small Business Administration’s Paycheck Protection Program (PPP) through the CARES Act.

“COVID-19 has had a tremendous impact especially on primary care practices. We live and die by volume. … Our volume in mid-March to mid-May really dropped dramatically,” explained Dr. Fincher, who is also president of the American College of Physicians. “The PPP sustained us for 2 months, enabling us to pay our staff and to remain open and get us up and running on telehealth.”
 

Starting up telemedicine

Experiencing spotty or no access to broadband Internet is nothing new to rural physicians, but having this problem interfere with their ability to provide care to patients is.

As much of the American health system rapidly embraced telehealth during the pandemic, obtaining access to high-speed Internet has been a major challenge for rural patients, noted Dr. Westfall.

“Some practices were able to quickly adopt some telehealth capacity with phone and video. Changes in payment for telehealth helped. But in some rural communities there was not adequate Internet bandwidth for quality video connections. And some patients did not have the means for high-speed video connections,” Dr. Westfall said.

Indeed, according to a 2019 Pew Research Center survey, 63% of rural Americans say they can access the Internet through a broadband connection at home, compared with 75% and 79% in suburban and urban areas, respectively.

G&P Productions

In the Appalachian town of Zanesville, Ohio, for example, family physician Shelly L. Dunmyer, MD, and her colleagues discovered that many patients don’t have Internet access at home. Dr. Fincher has to go to the office to conduct telehealth visits because her own Internet access at home is unpredictable. As for patients, it may take 15 minutes for them to work out technical glitches and find good Internet reception, said Dr. Fincher. For internist Y. Ki Shin, MD, who practices in the coastal town of Montesano in Washington state, about 25% of his practice’s telehealth visits must be conducted by phone because of limitations on video, such as lack of high-speed access.

But telephone visits are often insufficient replacements for appointments via video, according to several rural physicians interviewed for this piece.

“Telehealth can be frustrating at times due to connectivity issues which can be difficult at times in the rural areas,” said Dr. Fincher. “In order for telehealth to be reasonably helpful to patients and physicians to care for people with chronic problems, the patients must have things like blood pressure monitors, glucometers, and scales to address problems like hypertension, diabetes myelitis, and congestive heart failure.”

“If you have the audio and video and the data from these devices, you’re good. If you don’t have these data, and/or don’t have the video you just can’t provide good care,” she explained.

G&P Productions

Dr. Dunmyer and her colleagues at Medical Home Primary Care Center in Zanesville, Ohio, found a way to get around the problem of patients not being able to access Internet to participate in video visits from their homes. This involved having her patients drive into her practice’s parking lot to participate in modified telehealth visits. Staffers gave iPads to patients in their cars, and Dr. Dunmyer conducted visits from her office, about 50 yards away.

“We were even doing Medicare wellness visits: Instead of asking them to get up and move around the room, we would sit at the window and wave at them, ask them to get out, walk around the car. We were able to check mobility and all kinds of things that we’d normally do in the office,” Dr. Dunmyer explained in an interview.

The family physician noted that her practice is now conducting fewer parking lot visits since her office is allowing in-person appointments, but that they’re still an option for her patients.
 

Treating political adversaries

Some rural physicians have experienced strained relationships with patients for reasons other than technology – stark differences in opinion over the pandemic itself. Certain patients are following President Trump’s lead and questioning everything from the pandemic death toll to preventive measures recommended by scientists and medical experts, physicians interviewed by MDedge said.

Patients everywhere share these viewpoints, of course, but research and election results confirm that rural areas are more receptive to conservative viewpoints. In 2018, a Pew Research Center survey reported that rural and urban areas are “becoming more polarized politically,” and “rural areas tend to have a higher concentration of Republicans and Republican-leaning independents.” For example, 40% of rural respondents reported “very warm” or “somewhat warm” feelings toward Donald Trump, compared with just 19% in urban areas.

Dr. Shin has struggled to cope with patients who want to argue about pandemic safety precautions like wearing masks and seem to question whether systemic racism exists.

“We are seeing a lot more people who feel that this pandemic is not real, that it’s a political and not-true infection,” he said in an interview. “We’ve had patients who were angry at us because we made them wear masks, and some were demanding hydroxychloroquine and wanted to have an argument because we’re not going to prescribe it for them.”

In one situation, which he found especially disturbing, Dr. Shin had to leave the exam room because a patient wouldn’t stop challenging him regarding the pandemic. Things have gotten so bad that Dr. Shin has even questioned whether he wants to continue his long career in his small town because of local political attitudes such as opposition to mask-wearing and social distancing.

“Mr. Trump’s misinformation on this pandemic made my job much more difficult. As a minority, I feel less safe in my community than ever,” said Dr. Shin, who described himself as Asian American.

Despite these new stressors, Dr. Shin has experienced some joyful moments while practicing medicine in the pandemic.

Courtesy Dr. Clara Shin

He said a recent home visit to a patient who had been hospitalized for over 3 months and nearly died helped him put political disputes with his patients into perspective.

“He was discharged home but is bedbound. He had gangrene on his toes, and I could not fully examine him using video,” Dr. Shin recalled. “It was tricky to find the house, but a very large Trump sign was very helpful in locating it. It was a good visit: He was happy to see me, and I was happy to see that he was doing okay at home.”

“I need to remind myself that supporting Mr. Trump does not always mean that my patient supports Mr. Trump’s view on the pandemic and the race issues in our country,” Dr. Shin added.

The Washington-based internist said he also tells himself that, even if his patients refuse to follow his strong advice regarding pandemic precautions, it does not mean he has failed as a doctor.

“I need to continue to educate patients about the dangers of COVID infection but cannot be angry if they don’t choose to follow my recommendations,” he noted.

Dr. Fincher says her close connection with patients has allowed her to smooth over politically charged claims about the pandemic in the town of Thomson, Georgia, with a population 6,800.

“I have a sense that, even though we may differ in our understanding of some basic facts, they appreciate what I say since we have a long-term relationship built on trust,” she said. This kind of trust, Dr. Fincher suggested, may be more common than in urban areas where there’s a larger supply of physicians, and patients don’t see the same doctors for long periods of time.

“It’s more meaningful when it comes from me, rather than doctors who are [new to patients] every year when their employer changes their insurance,” she noted.

Rural primary care doctors are facing a new set of obstacles to practicing in the COVID-19 pandemic. These include struggling with seeing patients virtually and treating patients who have politicized the virus. Additionally, the pandemic has exposed rural practices to greater financial difficulties.

Courtesy Dr. Jacqueline W. Fincher

Before the pandemic some rurally based primary care physicians were already working through big challenges, such as having few local medical colleagues to consult and working in small practices with lean budgets. In fact, data gathered by the National Rural Health Association showed that there are only 40 primary care physicians per 100,000 patients in rural regions, compared with 53 in urban areas – and the number of physicians overall is 13 per 10,000 in rural areas, compared with 31 in cities.

In the prepandemic world, for some doctors, the challenges were balanced by the benefits of practicing in these sparsely populated communities with scenic, low-traffic roads. Some perks of practicing in rural areas touted by doctors included having a fast commute, being able to swim in a lake near the office before work, having a low cost of living, and feeling like they are making a difference in their communities as they treat generations of the families they see around town.

But today, new hurdles to practicing medicine in rural America created by the COVID-19 pandemic have caused the hardships to feel heavier than the joys at times for some physicians interviewed by MDedge.

Many independent rural practices in need of assistance were not able to get much from the federal Provider Relief Funds, said John M. Westfall, MD, who is director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, in an interview.

“Rural primary care doctors function independently or in smaller critical access hospitals and community health centers,” said Dr. Westfall, who previously practiced family medicine in a small town in Colorado. “Many of these have much less financial reserves so are at risk of cutbacks and closure.”

Jacqueline W. Fincher, MD, an internist based in a tiny Georgia community along the highway between Atlanta and Augusta, said her small practice works on really thin margins and doesn’t have much cushion. At the beginning of the pandemic, all visits were down, and her practice operated at a loss. To help, Dr. Fincher and her colleagues applied for funding from the Small Business Administration’s Paycheck Protection Program (PPP) through the CARES Act.

“COVID-19 has had a tremendous impact especially on primary care practices. We live and die by volume. … Our volume in mid-March to mid-May really dropped dramatically,” explained Dr. Fincher, who is also president of the American College of Physicians. “The PPP sustained us for 2 months, enabling us to pay our staff and to remain open and get us up and running on telehealth.”
 

Starting up telemedicine

Experiencing spotty or no access to broadband Internet is nothing new to rural physicians, but having this problem interfere with their ability to provide care to patients is.

As much of the American health system rapidly embraced telehealth during the pandemic, obtaining access to high-speed Internet has been a major challenge for rural patients, noted Dr. Westfall.

“Some practices were able to quickly adopt some telehealth capacity with phone and video. Changes in payment for telehealth helped. But in some rural communities there was not adequate Internet bandwidth for quality video connections. And some patients did not have the means for high-speed video connections,” Dr. Westfall said.

Indeed, according to a 2019 Pew Research Center survey, 63% of rural Americans say they can access the Internet through a broadband connection at home, compared with 75% and 79% in suburban and urban areas, respectively.

G&P Productions

In the Appalachian town of Zanesville, Ohio, for example, family physician Shelly L. Dunmyer, MD, and her colleagues discovered that many patients don’t have Internet access at home. Dr. Fincher has to go to the office to conduct telehealth visits because her own Internet access at home is unpredictable. As for patients, it may take 15 minutes for them to work out technical glitches and find good Internet reception, said Dr. Fincher. For internist Y. Ki Shin, MD, who practices in the coastal town of Montesano in Washington state, about 25% of his practice’s telehealth visits must be conducted by phone because of limitations on video, such as lack of high-speed access.

But telephone visits are often insufficient replacements for appointments via video, according to several rural physicians interviewed for this piece.

“Telehealth can be frustrating at times due to connectivity issues which can be difficult at times in the rural areas,” said Dr. Fincher. “In order for telehealth to be reasonably helpful to patients and physicians to care for people with chronic problems, the patients must have things like blood pressure monitors, glucometers, and scales to address problems like hypertension, diabetes myelitis, and congestive heart failure.”

“If you have the audio and video and the data from these devices, you’re good. If you don’t have these data, and/or don’t have the video you just can’t provide good care,” she explained.

G&P Productions

Dr. Dunmyer and her colleagues at Medical Home Primary Care Center in Zanesville, Ohio, found a way to get around the problem of patients not being able to access Internet to participate in video visits from their homes. This involved having her patients drive into her practice’s parking lot to participate in modified telehealth visits. Staffers gave iPads to patients in their cars, and Dr. Dunmyer conducted visits from her office, about 50 yards away.

“We were even doing Medicare wellness visits: Instead of asking them to get up and move around the room, we would sit at the window and wave at them, ask them to get out, walk around the car. We were able to check mobility and all kinds of things that we’d normally do in the office,” Dr. Dunmyer explained in an interview.

The family physician noted that her practice is now conducting fewer parking lot visits since her office is allowing in-person appointments, but that they’re still an option for her patients.
 

Treating political adversaries

Some rural physicians have experienced strained relationships with patients for reasons other than technology – stark differences in opinion over the pandemic itself. Certain patients are following President Trump’s lead and questioning everything from the pandemic death toll to preventive measures recommended by scientists and medical experts, physicians interviewed by MDedge said.

Patients everywhere share these viewpoints, of course, but research and election results confirm that rural areas are more receptive to conservative viewpoints. In 2018, a Pew Research Center survey reported that rural and urban areas are “becoming more polarized politically,” and “rural areas tend to have a higher concentration of Republicans and Republican-leaning independents.” For example, 40% of rural respondents reported “very warm” or “somewhat warm” feelings toward Donald Trump, compared with just 19% in urban areas.

Dr. Shin has struggled to cope with patients who want to argue about pandemic safety precautions like wearing masks and seem to question whether systemic racism exists.

“We are seeing a lot more people who feel that this pandemic is not real, that it’s a political and not-true infection,” he said in an interview. “We’ve had patients who were angry at us because we made them wear masks, and some were demanding hydroxychloroquine and wanted to have an argument because we’re not going to prescribe it for them.”

In one situation, which he found especially disturbing, Dr. Shin had to leave the exam room because a patient wouldn’t stop challenging him regarding the pandemic. Things have gotten so bad that Dr. Shin has even questioned whether he wants to continue his long career in his small town because of local political attitudes such as opposition to mask-wearing and social distancing.

“Mr. Trump’s misinformation on this pandemic made my job much more difficult. As a minority, I feel less safe in my community than ever,” said Dr. Shin, who described himself as Asian American.

Despite these new stressors, Dr. Shin has experienced some joyful moments while practicing medicine in the pandemic.

Courtesy Dr. Clara Shin

He said a recent home visit to a patient who had been hospitalized for over 3 months and nearly died helped him put political disputes with his patients into perspective.

“He was discharged home but is bedbound. He had gangrene on his toes, and I could not fully examine him using video,” Dr. Shin recalled. “It was tricky to find the house, but a very large Trump sign was very helpful in locating it. It was a good visit: He was happy to see me, and I was happy to see that he was doing okay at home.”

“I need to remind myself that supporting Mr. Trump does not always mean that my patient supports Mr. Trump’s view on the pandemic and the race issues in our country,” Dr. Shin added.

The Washington-based internist said he also tells himself that, even if his patients refuse to follow his strong advice regarding pandemic precautions, it does not mean he has failed as a doctor.

“I need to continue to educate patients about the dangers of COVID infection but cannot be angry if they don’t choose to follow my recommendations,” he noted.

Dr. Fincher says her close connection with patients has allowed her to smooth over politically charged claims about the pandemic in the town of Thomson, Georgia, with a population 6,800.

“I have a sense that, even though we may differ in our understanding of some basic facts, they appreciate what I say since we have a long-term relationship built on trust,” she said. This kind of trust, Dr. Fincher suggested, may be more common than in urban areas where there’s a larger supply of physicians, and patients don’t see the same doctors for long periods of time.

“It’s more meaningful when it comes from me, rather than doctors who are [new to patients] every year when their employer changes their insurance,” she noted.

HM20 Virtual session title

When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics
 

Presenter

Kimberly Manning, MD, FACP, FAAP
 

Session summary

Dr. Kimberly Manning, associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, masterfully discussed the dual pandemics of COVID-19 and racism that we are currently experiencing and tried to describe the unique perspective of Black Americans.

Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. She gave a great analogy: when sticking your hand into a bowl of Lucky Charms cereal, you do not expect to always end up with marshmallows alone, yet repeatedly, we see that Black Americans have been disproportionately affected by COVID-19. We often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this.

Dr. Manning discussed the life stories of her grandfather, her father, and even her own life’s milestones such as starting college, getting into medical school, finishing residency – all the way to becoming a full professor. She described how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile and laugh, there was something awful happening in the country simultaneously that showed us how racism was still present. Though this was one person’s story, all Black Americans, not just those working in health care, can recount similar stories, emotions, and feelings of grief.

Dr. Manning concluded by telling us how we can “Do the Work” to combat the pandemic of racism:

• Broaden your fund of knowledge: Read books, listen to podcasts, watch documentaries.
• Remember that people are grieving.
• Explore your implicit biases.
• Be a brave bystander.
• Avoid performative allyship.

Key takeaways

• Though the COVID-19 pandemic is unprecedented, the pandemic of racism is not.
• The story of COVID-19 is the story of social determinants of health.
• We all must “Do the Work” to combat everyday racism and be cognizant of what our Black colleagues are going through every day.

Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, Columbus.

HM20 Virtual session title

When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics
 

Presenter

Kimberly Manning, MD, FACP, FAAP
 

Session summary

Dr. Kimberly Manning, associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, masterfully discussed the dual pandemics of COVID-19 and racism that we are currently experiencing and tried to describe the unique perspective of Black Americans.

Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. She gave a great analogy: when sticking your hand into a bowl of Lucky Charms cereal, you do not expect to always end up with marshmallows alone, yet repeatedly, we see that Black Americans have been disproportionately affected by COVID-19. We often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this.

Dr. Manning discussed the life stories of her grandfather, her father, and even her own life’s milestones such as starting college, getting into medical school, finishing residency – all the way to becoming a full professor. She described how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile and laugh, there was something awful happening in the country simultaneously that showed us how racism was still present. Though this was one person’s story, all Black Americans, not just those working in health care, can recount similar stories, emotions, and feelings of grief.

Dr. Manning concluded by telling us how we can “Do the Work” to combat the pandemic of racism:

• Broaden your fund of knowledge: Read books, listen to podcasts, watch documentaries.
• Remember that people are grieving.
• Explore your implicit biases.
• Be a brave bystander.
• Avoid performative allyship.

Key takeaways

• Though the COVID-19 pandemic is unprecedented, the pandemic of racism is not.
• The story of COVID-19 is the story of social determinants of health.
• We all must “Do the Work” to combat everyday racism and be cognizant of what our Black colleagues are going through every day.

Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, Columbus.

HM20 Virtual session title

When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics
 

Presenter

Kimberly Manning, MD, FACP, FAAP
 

Session summary

Dr. Kimberly Manning, associate vice chair of diversity, equity, and inclusion at Emory University, Atlanta, masterfully discussed the dual pandemics of COVID-19 and racism that we are currently experiencing and tried to describe the unique perspective of Black Americans.

Though it is easy to see that COVID-19 is a pandemic, racism is not always seen in this way. Dr. Manning demonstrated that when a pandemic is defined as “that which occurs over a wide geographic area and affects a high proportion of the population,” racism is absolutely a pandemic. She gave a great analogy: when sticking your hand into a bowl of Lucky Charms cereal, you do not expect to always end up with marshmallows alone, yet repeatedly, we see that Black Americans have been disproportionately affected by COVID-19. We often hear that we are in unprecedented times but as far as racism is concerned, there is nothing new about this.

Dr. Manning discussed the life stories of her grandfather, her father, and even her own life’s milestones such as starting college, getting into medical school, finishing residency – all the way to becoming a full professor. She described how each of these instances, though marked by something beautiful, was also marked by something truly awful. Each time she had a reason to smile and laugh, there was something awful happening in the country simultaneously that showed us how racism was still present. Though this was one person’s story, all Black Americans, not just those working in health care, can recount similar stories, emotions, and feelings of grief.

Dr. Manning concluded by telling us how we can “Do the Work” to combat the pandemic of racism:

• Broaden your fund of knowledge: Read books, listen to podcasts, watch documentaries.
• Remember that people are grieving.
• Explore your implicit biases.
• Be a brave bystander.
• Avoid performative allyship.

Key takeaways

• Though the COVID-19 pandemic is unprecedented, the pandemic of racism is not.
• The story of COVID-19 is the story of social determinants of health.
• We all must “Do the Work” to combat everyday racism and be cognizant of what our Black colleagues are going through every day.

Dr. Doraiswamy is an assistant professor of medicine and pediatrics and a med-peds hospitalist at The Ohio State University and Nationwide Children’s Hospital, Columbus.

Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.

While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.

Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.

Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.

While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.

Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.

Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.

While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.

Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.

A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.

Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.

An opportune moment

Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”

Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.

Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.

“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.

The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.

Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.

Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
 

‘Uniquely isolated’

Dr. Margolis noted that clinicians “are uniquely isolated, especially those with children” because many parents do not want their children mingling with children of HCPs.

“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.

Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.

Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.

Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.

“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
 

‘Battle buddies’

Dr. Margolis recommended the “battle buddy” model for mutual peer support.

Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.

Self-care critical

Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”

Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.

The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”

They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.

The authors and Dr. Shaker disclosed no relevant financial relationships.

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

A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.

Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.

An opportune moment

Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”

Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.

Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.

“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.

The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.

Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.

Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
 

‘Uniquely isolated’

Dr. Margolis noted that clinicians “are uniquely isolated, especially those with children” because many parents do not want their children mingling with children of HCPs.

“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.

Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.

Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.

Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.

“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
 

‘Battle buddies’

Dr. Margolis recommended the “battle buddy” model for mutual peer support.

Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.

Self-care critical

Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”

Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.

The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”

They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.

The authors and Dr. Shaker disclosed no relevant financial relationships.

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

A new review offers fresh guidance to help stem the mental health toll of the COVID-19 pandemic on frontline clinicians.

Investigators gathered practice guidelines and resources from a wide range of health care organizations and professional societies to develop a conceptual framework of mental health support for health care professionals (HCPs) caring for COVID-19 patients.

An opportune moment

Coauthor Rebecca Margolis, DO, director of well-being in the division of medical education and faculty development, Children’s Hospital of Los Angeles, said that this is “an opportune moment to look at how we treat frontline providers in this country.”

Studies of previous pandemics have shown heightened distress in HCPs, even years after the pandemic, and the unique challenges posed by the COVID-19 pandemic surpass those of previous pandemics, Dr. Margolis said in an interview.

Dr. Schwartz, Dr. Margolis, and coauthors Uma Anand, PhD, LP, and Jina Sinskey, MD, met through the Collaborative for Healing and Renewal in Medicine network, a group of medical educators, leaders in academic medicine, experts in burnout research and interventions, and trainees working together to promote well-being among trainees and practicing physicians.

“We were brought together on a conference call in March, when things were particularly bad in New York, and started looking to see what resources we could get to frontline providers who were suffering. It was great to lean on each other and stand on the shoulders of colleagues in New York, who were the ones we learned from on these calls,” said Dr. Margolis.

The authors recommended addressing clinicians’ basic practical needs, including ensuring essentials like meals and transportation, establishing a “well-being area” within hospitals for staff to rest, and providing well-stocked living quarters so clinicians can safely quarantine from family, as well as personal protective equipment and child care.

Clinicians are often asked to “assume new professional roles to meet evolving needs” during a pandemic, which can increase stress. The authors recommended targeted training, assessment of clinician skills before redeployment to a new clinical role, and clear communication practices around redeployment.

Recognition from hospital and government leaders improves morale and supports clinicians’ ability to continue delivering care. Leadership should “leverage communication strategies to provide clinicians with up-to-date information and reassurance,” they wrote.
 

‘Uniquely isolated’

Dr. Margolis noted that clinicians “are uniquely isolated, especially those with children” because many parents do not want their children mingling with children of HCPs.

“My colleagues feel a sense of moral injury, putting their lives on the line at work, performing the most perilous job, and their kids can’t hang out with other kids, which just puts salt on the wound,” she said.

Additional sources of moral injury are deciding which patients should receive life support in the event of inadequate resources and bearing witness to, or enforcing, policies that lead to patients dying alone.

Leaders should encourage clinicians to “seek informal support from colleagues, managers, or chaplains” and to “provide rapid access to professional help,” the authors noted.

Furthermore, they contended that leaders should “proactively and routinely monitor the psychological well-being of their teams,” since guilt and shame often prevent clinicians from disclosing feelings of moral injury.

“Being provided with routine mental health support should be normalized and it should be part of the job – not only during COVID-19 but in general,” Dr. Schwartz said.
 

‘Battle buddies’

Dr. Margolis recommended the “battle buddy” model for mutual peer support.

Dr. Anand, a mental health clinician at Mayo Medical School, Rochester, Minn., elaborated.

Self-care critical

Marcus S. Shaker, MD, MSc, associate professor of pediatrics, medicine, and community and family medicine, Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., and Geisel School of Medicine at Dartmouth, Hanover, N.H., said the study was “a much appreciated, timely reminder of the importance of clinician wellness.”

Moreover, “without self-care, our ability to help our patients withers. This article provides a useful conceptual framework for individuals and organizations to provide the right care at the right time in these unprecedented times,” said Dr. Shaker, who was not involved with the study.

The authors agreed, stating that clinicians “require proactive psychological protection specifically because they are a population known for putting others’ needs before their own.”

They recommended several resources for HCPs, including the Physician Support Line; Headspace, a mindfulness Web-based app for reducing stress and anxiety; the National Suicide Prevention Lifeline; and the Crisis Text Line.

The authors and Dr. Shaker disclosed no relevant financial relationships.

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

Every 2 years the Society of Hospital Medicine’s Practice Analysis Committee (PAC) surveys hospitalist groups nationwide on such key practice parameters as compensation, services provided, hours of work, and participation in leadership roles. Combined with compensation and productivity data on adult and pediatric hospitalists collected by the Medical Group Management Association, licensed to SHM for inclusion in this report, the State of Hospital Medicine (SoHM) report is the most authoritative and comprehensive source of information regarding contemporary hospitalist practice.

This year’s biannual report is based on survey responses submitted between Jan. 6 and Feb. 28, 2020, by 502 hospitalist group practices. That’s slightly fewer groups reporting data than for past surveys, but these groups were larger, on average, resulting in more full-time equivalents (FTEs) incorporated into the results, said PAC member Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. A total of 19.7% of the reporting groups provided pediatric hospital medicine data only, a much larger proportion than in past years.

The report is slated for publication in September, and SHM members can purchase it at a discount in print or electronic versions. “Our sense is that a lot of the fundamental information in the report will not have changed that much from 2018,” Ms. Flores said. “But these results convey the state of the field prior to the world-altering impact of the COVID-19 pandemic on hospitals of all sizes and settings.” How the hospital business and the practice of hospitalist groups have been and will be impacted by the pandemic, obviously, aren’t reflected in the data.

“We are finalizing a supplemental survey to go out to members at the end of the summer, specifically asking how COVID has impacted their hospitalist groups,” Ms. Flores said. These COVID-19 supplemental results will be released after the main report, sometime around the end of September. But results from the main survey, showing consistency in a number of key parameters, indicate that hospitalists continue to have a large and essential role in the U.S. health care system.

The leadership offered by hospitalists in the U.S. health care system’s response to surges of COVID-19 patients in many hospitals only underscores their importance, Ms. Flores added. “Hospitalists have definitely proven their worth. Imagine what the pandemic would have been like for hospitals if our specialty hadn’t been well-positioned to respond.” Hospitalists also showed an ability to adapt quickly to crises on the ground. But financial pressures imposed by the pandemic, combined with other trends previously in play, suggest that demands to cut costs and do more with less will be relentless as the field – and the world – tries to pull out of the pandemic crisis.
 

Compensation trends

One of the most eagerly anticipated findings in the SoHM is compensation. The median compensation for all adult hospitalists at the beginning of 2020 was $307,633 (with an average of $317,640), higher in the Midwest and lower in the East. The average base rate share of hospitalist compensation was 81.3%, with 11.6% based on productivity and 7.1% for performance – scored on such measures as patient satisfaction; accuracy and/or timeliness of documentation, billing, and coding; clinical processes; early morning discharge orders and times; and readmissions rates. A total of 46.6% of responding groups said they anticipated an increase in budgeted FTEs in the next year, while 51.2% expected to stay the same.

Subsidies or financial support for hospitalist practices break down in different ways, but in 2020 the median figure for financial support provided per adult hospitalist FTE was $198,750 (average, $201,760). This suggests that hospitals continue to see hospitalists as valued partners in health care, with useful knowledge of how the various components of the health care system work, said Tresa McNeal, MD, a hospitalist at Baylor Scott & White Medical Center, Temple, Tex., and a member of the PAC.
 

Scope of practice

Scope of practice for the hospitalist model continues to evolve, with increased demand for comanagement roles as other medical specialties are less inclined to visit patients in the hospital. Surgical comanagement accounted for much of that growth, but there were significant rates of comanagement for neurology, gastrointestinal and liver medicine, cardiology, and palliative care.

“Comanagement is a broad term without a single clear definition,” Ms. Flores said. “But when I talk about it, I refer to a broader array of hospitalists interacting with specialists.” The hospitalist‘s role could be as a consultant, or taking responsibility for admitting and attending.

Other identified roles played by hospitalists in adult-only groups included providing care for patients in the ICU (59.6% of reporting groups); primary responsibility for observation/short stay units, rapid response teams or code blue/cardiac arrest teams; cross-coverage for patients admitted without a hospitalist; and performing procedures such as vascular access, lumbar puncture, paracentesis, and thoracentesis. The hospitalist role’s in the ICU likely increased in many hospitals confronting COVID surges, Ms. Flores said.

The median number of shifts performed per year by a full-time hospitalist physician was 182.0 (average, 182.3), with 12 hours as the most common average duration for a shift in a daytime schedule. The 7-days-on/7-days-off model remained the most popular way to schedule adult hospitalists, at the same rate as in 2018. Backup coverage is another important issue for hospitalist groups, with 52.6% reporting no formal backup system. For those with a backup system, the highest proportion paid no additional compensation to the physician for being on the on-call schedule, but additional compensation was paid if called into the hospital.

Presence of nocturnists was reported by 71.9% of responding groups, slightly down from 2018, but increasing with the size of the group. “We continue to see a trend for dedicated nocturnists,” said Dr. McNeal. Hospitals see the benefits from the presence of a nocturnist, reflected in pay differentials or requiring fewer full-time shifts from nocturnists. It’s more consistent, higher quality of care delivered by people who are dedicated to that role.

In other findings from the survey, turnover in adult hospitalist groups is 10.9%t, which is up from 2018 but down from 2016. Unit-based assignment, also known as geographical rounding, was utilized by 42.7% of responding adult groups, with likelihood increasing with the size of the group. Unfilled positions were reported by 73.5% of groups, with an average of 11.2% of positions unfilled at the time of the survey.

The use of telemedicine in the hospital setting is evolving, likely considerably accelerated of necessity by the pandemic. “Many of us are using telemedicine with COVID patients in order to decrease clinicians’ time in the room, and to find a way to use a work force that has to be on leave,” Dr. McNeal said.
 

Nurse practitioners and physician assistants

The role for nurse practitioners and physician assistants in adult hospital medicine groups continues to increase, with 83.3% of groups reporting the presence of PAs and NPs, up from 77% in 2018. NPs/PAs are more likely in multistate hospitalist groups or integrated delivery system practices in hospitals/health systems.

The most common billing model for their professional services is a combination of independent billing by the PA/NP where allowed and shared services billing under a supervisory physician’s provider number – although 8.1% of groups report that their NPs/PAs didn’t generally provide billable services or submit bills for payment.

NPs and PAs spend one-fifth of their time, on average, on nonbillable, value-added work, including dedicated cross-coverage shifts, scheduling, patient assignments, nonbillable clinical work such as glycemic control, and quality improvement and performance improvement activities. “This is one example of the changing skill mix for the hospitalist group, helping the practice become more efficient,” Ms. Flores said.

NPs and PAs provide valuable services, Dr. McNeal added. “But it also takes some investment in time and training for them to be able to practice at the top of their license. My own hospitalist group has a training program for newly hired NPs/PAs. Everyone goes through this orientation for around 6-10 weeks, largely in a shadowing role starting out, until they gradually adjust to more clinical autonomy.”

This onboarding includes real-time evaluations and self-evaluations, and opportunities for conversations with experienced clinicians, working from a list of 30 “bread-and-butter” topics in hospital medicine, she noted.
 

Pediatric hospital medicine

The 2020 SoHM report includes a greater representation for pediatric hospital medicine, with a 200% increase in the proportion of reporting hospitalist groups that only take care of children. Thus, the pediatric data are more robust – and helpful – than in prior year surveys, said Sandra Gage, MD, SFHM, a pediatric hospitalist at Phoenix Children’s Hospital. Dr. Gage headed up the PAC’s expanded pediatric data initiative, with targeted outreach to pediatric groups to encourage their participation. She also convened a task force to come up with pediatric-specific questions that were more pertinent and user friendly.

One of the important questions for pediatric hospitalists involves scheduling – including variations in length of shifts – which can vary dramatically in pediatric HM groups. “This year we reported by number of hours expected for a clinical FTE, which should be more useful for group leaders,” Dr. Gage said. The median number of hours required per FTE from pediatric hospitalists was fairly consistent at 1,800 per year, with minor variations based on region and academic status.

“I don’t know that there’s anything too surprising in most of the data,” she said, but noted that SHM will now have a better pediatric baseline going forward. The survey also asked how many pediatric hospitalists were board certified in the new subspecialty of pediatric hospital medicine under the program launched last year by the American Board of Pediatrics. Its first qualifying exam was in November 2019. The average was 26%, but the variation between academic and nonacademic programs was unexpected, Dr. Gage said.

Pediatric hospitalists come from a variety of professional specialties besides pediatrics. Nearly half of all programs had at least one med/peds provider, while a smaller number of programs had providers from family medicine, internal medicine, emergency medicine, or palliative care, she noted. Half of pediatric hospitalists reported joining their practice directly out of residency. About 26% of pediatric hospital medicine (PHM) physicians were described as part time, and 34.3% of pediatric groups had the presence of an NP or PA.

“I think PHM evolved a little later than for adult hospitalists, but it has clearly come into its own as a field,” Dr. Gage said. In the COVID-19 crisis, some pediatric hospitalists have been asked to care for adult patients, which necessitated a flurry of activity to refresh their medical knowledge. Where pediatric units existed within the walls of adult hospitals and were temporarily closed for COVID, it’s not clear how many will reopen – perhaps ever.
 

Long-term impacts of the crisis

Some of the hospitalist group leaders Ms. Flores has spoken with in recent months point out that, while New York and some other early COVID-19 hot spots experienced a tremendous surge of patients and hospital crowding in March and April 2020, other hospitals didn’t see anywhere near the impact.

“For some, there was nothing going on with COVID where they were,” she said. Elective surgeries were widely canceled, but with no corresponding increase of COVID admissions; and with fewer patients showing up in EDs, some physicians found themselves idled.

What will be the longer-term impact of COVID-19? How will it change hospital medicine? “I definitely think things are going to change,” Ms. Flores said, speculating that licensing boards could find a way to make it easier for physicians to practice across state lines in response to crises like the pandemic. “Do we need to think at the national level about what we can do to create more surge capacity, to move people when and where they need to go in a crisis? Are there things SHM could do to help?”

Ms. Flores expects more hospital closures than followed the 2008-2009 economic recession, which likely will further drive the trend toward mergers and acquisitions – both of hospitalist groups and of hospitals.

“From the point of view of hospitals, financial pressures will only get worse, pressing us to reinvent how hospitalists work and how that could be made more efficient,” she said. “I hear hospitals saying: ‘We can’t sustain current trends.’ Meanwhile, specialists are saying they need more help from hospitalists, and frontline hospitalists are saying they’re already working too hard. What will we do about burnout?”

These competing trends were all headed toward a perfect storm even before the epidemic hit, Ms. Flores said. “The response will require some innovations we haven’t yet conceived of. Incremental change won’t get us where we need to be. But the hospitalist’s role will be more essential than ever.”

The 2020 data show that a lot of things have been fairly steady for hospitalists, said Thomas Frederickson, MD, a member of SHM’s PAC and a specialist in hospital medicine at CHI Health in Omaha, Neb. But one concern about this stability is that, while hospitalist compensation continues to go up, workload and by extension productivity remain relatively flat. “That has been a trend over the past decade, and some of us find it hard to make sense of that.”

Dr. Frederickson, too, sees a need for disruptive innovation. “I just wish I knew what that will be.” Perhaps, just as hospitalists played a large role in the quality revolution in hospitals over the past decade, maybe in the next decade they will come to play a large role in the right-sizing of hospital care in health systems, he said.

One other important finding: the number of hospitalists per group who play roles as physician leaders has also increased, with an average of 3.2 physicians per group in a formal leadership role (median of 2). But currently, 73% of the highest-ranking leaders in hospitalist groups are male, and they are disproportionally white. As reported in Medscape in 2019, 40% of working hospitalists are women and only 36% of hospitalists overall self-identified as White.¹

“When you think of the demographics of actual working hospitalists, we could say the field of hospital medicine could and should do better in creating opportunities for diversity in leadership roles,” Ms. Flores said.
 

Reference

1. Martin KL. Hospitalist Compensation Report for 2019. Medscape. 2019 Jun 5. https://www.medscape.com/slideshow/2019-compensation-hospitalist-6011429#3.

Every 2 years the Society of Hospital Medicine’s Practice Analysis Committee (PAC) surveys hospitalist groups nationwide on such key practice parameters as compensation, services provided, hours of work, and participation in leadership roles. Combined with compensation and productivity data on adult and pediatric hospitalists collected by the Medical Group Management Association, licensed to SHM for inclusion in this report, the State of Hospital Medicine (SoHM) report is the most authoritative and comprehensive source of information regarding contemporary hospitalist practice.

This year’s biannual report is based on survey responses submitted between Jan. 6 and Feb. 28, 2020, by 502 hospitalist group practices. That’s slightly fewer groups reporting data than for past surveys, but these groups were larger, on average, resulting in more full-time equivalents (FTEs) incorporated into the results, said PAC member Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. A total of 19.7% of the reporting groups provided pediatric hospital medicine data only, a much larger proportion than in past years.

The report is slated for publication in September, and SHM members can purchase it at a discount in print or electronic versions. “Our sense is that a lot of the fundamental information in the report will not have changed that much from 2018,” Ms. Flores said. “But these results convey the state of the field prior to the world-altering impact of the COVID-19 pandemic on hospitals of all sizes and settings.” How the hospital business and the practice of hospitalist groups have been and will be impacted by the pandemic, obviously, aren’t reflected in the data.

“We are finalizing a supplemental survey to go out to members at the end of the summer, specifically asking how COVID has impacted their hospitalist groups,” Ms. Flores said. These COVID-19 supplemental results will be released after the main report, sometime around the end of September. But results from the main survey, showing consistency in a number of key parameters, indicate that hospitalists continue to have a large and essential role in the U.S. health care system.

The leadership offered by hospitalists in the U.S. health care system’s response to surges of COVID-19 patients in many hospitals only underscores their importance, Ms. Flores added. “Hospitalists have definitely proven their worth. Imagine what the pandemic would have been like for hospitals if our specialty hadn’t been well-positioned to respond.” Hospitalists also showed an ability to adapt quickly to crises on the ground. But financial pressures imposed by the pandemic, combined with other trends previously in play, suggest that demands to cut costs and do more with less will be relentless as the field – and the world – tries to pull out of the pandemic crisis.
 

Compensation trends

One of the most eagerly anticipated findings in the SoHM is compensation. The median compensation for all adult hospitalists at the beginning of 2020 was $307,633 (with an average of $317,640), higher in the Midwest and lower in the East. The average base rate share of hospitalist compensation was 81.3%, with 11.6% based on productivity and 7.1% for performance – scored on such measures as patient satisfaction; accuracy and/or timeliness of documentation, billing, and coding; clinical processes; early morning discharge orders and times; and readmissions rates. A total of 46.6% of responding groups said they anticipated an increase in budgeted FTEs in the next year, while 51.2% expected to stay the same.

Subsidies or financial support for hospitalist practices break down in different ways, but in 2020 the median figure for financial support provided per adult hospitalist FTE was $198,750 (average, $201,760). This suggests that hospitals continue to see hospitalists as valued partners in health care, with useful knowledge of how the various components of the health care system work, said Tresa McNeal, MD, a hospitalist at Baylor Scott & White Medical Center, Temple, Tex., and a member of the PAC.
 

Scope of practice

Scope of practice for the hospitalist model continues to evolve, with increased demand for comanagement roles as other medical specialties are less inclined to visit patients in the hospital. Surgical comanagement accounted for much of that growth, but there were significant rates of comanagement for neurology, gastrointestinal and liver medicine, cardiology, and palliative care.

“Comanagement is a broad term without a single clear definition,” Ms. Flores said. “But when I talk about it, I refer to a broader array of hospitalists interacting with specialists.” The hospitalist‘s role could be as a consultant, or taking responsibility for admitting and attending.

Other identified roles played by hospitalists in adult-only groups included providing care for patients in the ICU (59.6% of reporting groups); primary responsibility for observation/short stay units, rapid response teams or code blue/cardiac arrest teams; cross-coverage for patients admitted without a hospitalist; and performing procedures such as vascular access, lumbar puncture, paracentesis, and thoracentesis. The hospitalist role’s in the ICU likely increased in many hospitals confronting COVID surges, Ms. Flores said.

The median number of shifts performed per year by a full-time hospitalist physician was 182.0 (average, 182.3), with 12 hours as the most common average duration for a shift in a daytime schedule. The 7-days-on/7-days-off model remained the most popular way to schedule adult hospitalists, at the same rate as in 2018. Backup coverage is another important issue for hospitalist groups, with 52.6% reporting no formal backup system. For those with a backup system, the highest proportion paid no additional compensation to the physician for being on the on-call schedule, but additional compensation was paid if called into the hospital.

Presence of nocturnists was reported by 71.9% of responding groups, slightly down from 2018, but increasing with the size of the group. “We continue to see a trend for dedicated nocturnists,” said Dr. McNeal. Hospitals see the benefits from the presence of a nocturnist, reflected in pay differentials or requiring fewer full-time shifts from nocturnists. It’s more consistent, higher quality of care delivered by people who are dedicated to that role.

In other findings from the survey, turnover in adult hospitalist groups is 10.9%t, which is up from 2018 but down from 2016. Unit-based assignment, also known as geographical rounding, was utilized by 42.7% of responding adult groups, with likelihood increasing with the size of the group. Unfilled positions were reported by 73.5% of groups, with an average of 11.2% of positions unfilled at the time of the survey.

The use of telemedicine in the hospital setting is evolving, likely considerably accelerated of necessity by the pandemic. “Many of us are using telemedicine with COVID patients in order to decrease clinicians’ time in the room, and to find a way to use a work force that has to be on leave,” Dr. McNeal said.
 

Nurse practitioners and physician assistants

The role for nurse practitioners and physician assistants in adult hospital medicine groups continues to increase, with 83.3% of groups reporting the presence of PAs and NPs, up from 77% in 2018. NPs/PAs are more likely in multistate hospitalist groups or integrated delivery system practices in hospitals/health systems.

The most common billing model for their professional services is a combination of independent billing by the PA/NP where allowed and shared services billing under a supervisory physician’s provider number – although 8.1% of groups report that their NPs/PAs didn’t generally provide billable services or submit bills for payment.

NPs and PAs spend one-fifth of their time, on average, on nonbillable, value-added work, including dedicated cross-coverage shifts, scheduling, patient assignments, nonbillable clinical work such as glycemic control, and quality improvement and performance improvement activities. “This is one example of the changing skill mix for the hospitalist group, helping the practice become more efficient,” Ms. Flores said.

NPs and PAs provide valuable services, Dr. McNeal added. “But it also takes some investment in time and training for them to be able to practice at the top of their license. My own hospitalist group has a training program for newly hired NPs/PAs. Everyone goes through this orientation for around 6-10 weeks, largely in a shadowing role starting out, until they gradually adjust to more clinical autonomy.”

This onboarding includes real-time evaluations and self-evaluations, and opportunities for conversations with experienced clinicians, working from a list of 30 “bread-and-butter” topics in hospital medicine, she noted.
 

Pediatric hospital medicine

The 2020 SoHM report includes a greater representation for pediatric hospital medicine, with a 200% increase in the proportion of reporting hospitalist groups that only take care of children. Thus, the pediatric data are more robust – and helpful – than in prior year surveys, said Sandra Gage, MD, SFHM, a pediatric hospitalist at Phoenix Children’s Hospital. Dr. Gage headed up the PAC’s expanded pediatric data initiative, with targeted outreach to pediatric groups to encourage their participation. She also convened a task force to come up with pediatric-specific questions that were more pertinent and user friendly.

One of the important questions for pediatric hospitalists involves scheduling – including variations in length of shifts – which can vary dramatically in pediatric HM groups. “This year we reported by number of hours expected for a clinical FTE, which should be more useful for group leaders,” Dr. Gage said. The median number of hours required per FTE from pediatric hospitalists was fairly consistent at 1,800 per year, with minor variations based on region and academic status.

“I don’t know that there’s anything too surprising in most of the data,” she said, but noted that SHM will now have a better pediatric baseline going forward. The survey also asked how many pediatric hospitalists were board certified in the new subspecialty of pediatric hospital medicine under the program launched last year by the American Board of Pediatrics. Its first qualifying exam was in November 2019. The average was 26%, but the variation between academic and nonacademic programs was unexpected, Dr. Gage said.

Pediatric hospitalists come from a variety of professional specialties besides pediatrics. Nearly half of all programs had at least one med/peds provider, while a smaller number of programs had providers from family medicine, internal medicine, emergency medicine, or palliative care, she noted. Half of pediatric hospitalists reported joining their practice directly out of residency. About 26% of pediatric hospital medicine (PHM) physicians were described as part time, and 34.3% of pediatric groups had the presence of an NP or PA.

“I think PHM evolved a little later than for adult hospitalists, but it has clearly come into its own as a field,” Dr. Gage said. In the COVID-19 crisis, some pediatric hospitalists have been asked to care for adult patients, which necessitated a flurry of activity to refresh their medical knowledge. Where pediatric units existed within the walls of adult hospitals and were temporarily closed for COVID, it’s not clear how many will reopen – perhaps ever.
 

Long-term impacts of the crisis

Some of the hospitalist group leaders Ms. Flores has spoken with in recent months point out that, while New York and some other early COVID-19 hot spots experienced a tremendous surge of patients and hospital crowding in March and April 2020, other hospitals didn’t see anywhere near the impact.

“For some, there was nothing going on with COVID where they were,” she said. Elective surgeries were widely canceled, but with no corresponding increase of COVID admissions; and with fewer patients showing up in EDs, some physicians found themselves idled.

What will be the longer-term impact of COVID-19? How will it change hospital medicine? “I definitely think things are going to change,” Ms. Flores said, speculating that licensing boards could find a way to make it easier for physicians to practice across state lines in response to crises like the pandemic. “Do we need to think at the national level about what we can do to create more surge capacity, to move people when and where they need to go in a crisis? Are there things SHM could do to help?”

Ms. Flores expects more hospital closures than followed the 2008-2009 economic recession, which likely will further drive the trend toward mergers and acquisitions – both of hospitalist groups and of hospitals.

“From the point of view of hospitals, financial pressures will only get worse, pressing us to reinvent how hospitalists work and how that could be made more efficient,” she said. “I hear hospitals saying: ‘We can’t sustain current trends.’ Meanwhile, specialists are saying they need more help from hospitalists, and frontline hospitalists are saying they’re already working too hard. What will we do about burnout?”

These competing trends were all headed toward a perfect storm even before the epidemic hit, Ms. Flores said. “The response will require some innovations we haven’t yet conceived of. Incremental change won’t get us where we need to be. But the hospitalist’s role will be more essential than ever.”

The 2020 data show that a lot of things have been fairly steady for hospitalists, said Thomas Frederickson, MD, a member of SHM’s PAC and a specialist in hospital medicine at CHI Health in Omaha, Neb. But one concern about this stability is that, while hospitalist compensation continues to go up, workload and by extension productivity remain relatively flat. “That has been a trend over the past decade, and some of us find it hard to make sense of that.”

Dr. Frederickson, too, sees a need for disruptive innovation. “I just wish I knew what that will be.” Perhaps, just as hospitalists played a large role in the quality revolution in hospitals over the past decade, maybe in the next decade they will come to play a large role in the right-sizing of hospital care in health systems, he said.

One other important finding: the number of hospitalists per group who play roles as physician leaders has also increased, with an average of 3.2 physicians per group in a formal leadership role (median of 2). But currently, 73% of the highest-ranking leaders in hospitalist groups are male, and they are disproportionally white. As reported in Medscape in 2019, 40% of working hospitalists are women and only 36% of hospitalists overall self-identified as White.¹

“When you think of the demographics of actual working hospitalists, we could say the field of hospital medicine could and should do better in creating opportunities for diversity in leadership roles,” Ms. Flores said.
 

Reference

1. Martin KL. Hospitalist Compensation Report for 2019. Medscape. 2019 Jun 5. https://www.medscape.com/slideshow/2019-compensation-hospitalist-6011429#3.

Every 2 years the Society of Hospital Medicine’s Practice Analysis Committee (PAC) surveys hospitalist groups nationwide on such key practice parameters as compensation, services provided, hours of work, and participation in leadership roles. Combined with compensation and productivity data on adult and pediatric hospitalists collected by the Medical Group Management Association, licensed to SHM for inclusion in this report, the State of Hospital Medicine (SoHM) report is the most authoritative and comprehensive source of information regarding contemporary hospitalist practice.

This year’s biannual report is based on survey responses submitted between Jan. 6 and Feb. 28, 2020, by 502 hospitalist group practices. That’s slightly fewer groups reporting data than for past surveys, but these groups were larger, on average, resulting in more full-time equivalents (FTEs) incorporated into the results, said PAC member Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. A total of 19.7% of the reporting groups provided pediatric hospital medicine data only, a much larger proportion than in past years.

The report is slated for publication in September, and SHM members can purchase it at a discount in print or electronic versions. “Our sense is that a lot of the fundamental information in the report will not have changed that much from 2018,” Ms. Flores said. “But these results convey the state of the field prior to the world-altering impact of the COVID-19 pandemic on hospitals of all sizes and settings.” How the hospital business and the practice of hospitalist groups have been and will be impacted by the pandemic, obviously, aren’t reflected in the data.

“We are finalizing a supplemental survey to go out to members at the end of the summer, specifically asking how COVID has impacted their hospitalist groups,” Ms. Flores said. These COVID-19 supplemental results will be released after the main report, sometime around the end of September. But results from the main survey, showing consistency in a number of key parameters, indicate that hospitalists continue to have a large and essential role in the U.S. health care system.

The leadership offered by hospitalists in the U.S. health care system’s response to surges of COVID-19 patients in many hospitals only underscores their importance, Ms. Flores added. “Hospitalists have definitely proven their worth. Imagine what the pandemic would have been like for hospitals if our specialty hadn’t been well-positioned to respond.” Hospitalists also showed an ability to adapt quickly to crises on the ground. But financial pressures imposed by the pandemic, combined with other trends previously in play, suggest that demands to cut costs and do more with less will be relentless as the field – and the world – tries to pull out of the pandemic crisis.
 

Compensation trends

One of the most eagerly anticipated findings in the SoHM is compensation. The median compensation for all adult hospitalists at the beginning of 2020 was $307,633 (with an average of $317,640), higher in the Midwest and lower in the East. The average base rate share of hospitalist compensation was 81.3%, with 11.6% based on productivity and 7.1% for performance – scored on such measures as patient satisfaction; accuracy and/or timeliness of documentation, billing, and coding; clinical processes; early morning discharge orders and times; and readmissions rates. A total of 46.6% of responding groups said they anticipated an increase in budgeted FTEs in the next year, while 51.2% expected to stay the same.

Subsidies or financial support for hospitalist practices break down in different ways, but in 2020 the median figure for financial support provided per adult hospitalist FTE was $198,750 (average, $201,760). This suggests that hospitals continue to see hospitalists as valued partners in health care, with useful knowledge of how the various components of the health care system work, said Tresa McNeal, MD, a hospitalist at Baylor Scott & White Medical Center, Temple, Tex., and a member of the PAC.
 

Scope of practice

Scope of practice for the hospitalist model continues to evolve, with increased demand for comanagement roles as other medical specialties are less inclined to visit patients in the hospital. Surgical comanagement accounted for much of that growth, but there were significant rates of comanagement for neurology, gastrointestinal and liver medicine, cardiology, and palliative care.

“Comanagement is a broad term without a single clear definition,” Ms. Flores said. “But when I talk about it, I refer to a broader array of hospitalists interacting with specialists.” The hospitalist‘s role could be as a consultant, or taking responsibility for admitting and attending.

Other identified roles played by hospitalists in adult-only groups included providing care for patients in the ICU (59.6% of reporting groups); primary responsibility for observation/short stay units, rapid response teams or code blue/cardiac arrest teams; cross-coverage for patients admitted without a hospitalist; and performing procedures such as vascular access, lumbar puncture, paracentesis, and thoracentesis. The hospitalist role’s in the ICU likely increased in many hospitals confronting COVID surges, Ms. Flores said.

The median number of shifts performed per year by a full-time hospitalist physician was 182.0 (average, 182.3), with 12 hours as the most common average duration for a shift in a daytime schedule. The 7-days-on/7-days-off model remained the most popular way to schedule adult hospitalists, at the same rate as in 2018. Backup coverage is another important issue for hospitalist groups, with 52.6% reporting no formal backup system. For those with a backup system, the highest proportion paid no additional compensation to the physician for being on the on-call schedule, but additional compensation was paid if called into the hospital.

Presence of nocturnists was reported by 71.9% of responding groups, slightly down from 2018, but increasing with the size of the group. “We continue to see a trend for dedicated nocturnists,” said Dr. McNeal. Hospitals see the benefits from the presence of a nocturnist, reflected in pay differentials or requiring fewer full-time shifts from nocturnists. It’s more consistent, higher quality of care delivered by people who are dedicated to that role.

In other findings from the survey, turnover in adult hospitalist groups is 10.9%t, which is up from 2018 but down from 2016. Unit-based assignment, also known as geographical rounding, was utilized by 42.7% of responding adult groups, with likelihood increasing with the size of the group. Unfilled positions were reported by 73.5% of groups, with an average of 11.2% of positions unfilled at the time of the survey.

The use of telemedicine in the hospital setting is evolving, likely considerably accelerated of necessity by the pandemic. “Many of us are using telemedicine with COVID patients in order to decrease clinicians’ time in the room, and to find a way to use a work force that has to be on leave,” Dr. McNeal said.
 

Nurse practitioners and physician assistants

The role for nurse practitioners and physician assistants in adult hospital medicine groups continues to increase, with 83.3% of groups reporting the presence of PAs and NPs, up from 77% in 2018. NPs/PAs are more likely in multistate hospitalist groups or integrated delivery system practices in hospitals/health systems.

The most common billing model for their professional services is a combination of independent billing by the PA/NP where allowed and shared services billing under a supervisory physician’s provider number – although 8.1% of groups report that their NPs/PAs didn’t generally provide billable services or submit bills for payment.

NPs and PAs spend one-fifth of their time, on average, on nonbillable, value-added work, including dedicated cross-coverage shifts, scheduling, patient assignments, nonbillable clinical work such as glycemic control, and quality improvement and performance improvement activities. “This is one example of the changing skill mix for the hospitalist group, helping the practice become more efficient,” Ms. Flores said.

NPs and PAs provide valuable services, Dr. McNeal added. “But it also takes some investment in time and training for them to be able to practice at the top of their license. My own hospitalist group has a training program for newly hired NPs/PAs. Everyone goes through this orientation for around 6-10 weeks, largely in a shadowing role starting out, until they gradually adjust to more clinical autonomy.”

This onboarding includes real-time evaluations and self-evaluations, and opportunities for conversations with experienced clinicians, working from a list of 30 “bread-and-butter” topics in hospital medicine, she noted.
 

Pediatric hospital medicine

The 2020 SoHM report includes a greater representation for pediatric hospital medicine, with a 200% increase in the proportion of reporting hospitalist groups that only take care of children. Thus, the pediatric data are more robust – and helpful – than in prior year surveys, said Sandra Gage, MD, SFHM, a pediatric hospitalist at Phoenix Children’s Hospital. Dr. Gage headed up the PAC’s expanded pediatric data initiative, with targeted outreach to pediatric groups to encourage their participation. She also convened a task force to come up with pediatric-specific questions that were more pertinent and user friendly.

One of the important questions for pediatric hospitalists involves scheduling – including variations in length of shifts – which can vary dramatically in pediatric HM groups. “This year we reported by number of hours expected for a clinical FTE, which should be more useful for group leaders,” Dr. Gage said. The median number of hours required per FTE from pediatric hospitalists was fairly consistent at 1,800 per year, with minor variations based on region and academic status.

“I don’t know that there’s anything too surprising in most of the data,” she said, but noted that SHM will now have a better pediatric baseline going forward. The survey also asked how many pediatric hospitalists were board certified in the new subspecialty of pediatric hospital medicine under the program launched last year by the American Board of Pediatrics. Its first qualifying exam was in November 2019. The average was 26%, but the variation between academic and nonacademic programs was unexpected, Dr. Gage said.

Pediatric hospitalists come from a variety of professional specialties besides pediatrics. Nearly half of all programs had at least one med/peds provider, while a smaller number of programs had providers from family medicine, internal medicine, emergency medicine, or palliative care, she noted. Half of pediatric hospitalists reported joining their practice directly out of residency. About 26% of pediatric hospital medicine (PHM) physicians were described as part time, and 34.3% of pediatric groups had the presence of an NP or PA.

“I think PHM evolved a little later than for adult hospitalists, but it has clearly come into its own as a field,” Dr. Gage said. In the COVID-19 crisis, some pediatric hospitalists have been asked to care for adult patients, which necessitated a flurry of activity to refresh their medical knowledge. Where pediatric units existed within the walls of adult hospitals and were temporarily closed for COVID, it’s not clear how many will reopen – perhaps ever.
 

Long-term impacts of the crisis

Some of the hospitalist group leaders Ms. Flores has spoken with in recent months point out that, while New York and some other early COVID-19 hot spots experienced a tremendous surge of patients and hospital crowding in March and April 2020, other hospitals didn’t see anywhere near the impact.

“For some, there was nothing going on with COVID where they were,” she said. Elective surgeries were widely canceled, but with no corresponding increase of COVID admissions; and with fewer patients showing up in EDs, some physicians found themselves idled.

What will be the longer-term impact of COVID-19? How will it change hospital medicine? “I definitely think things are going to change,” Ms. Flores said, speculating that licensing boards could find a way to make it easier for physicians to practice across state lines in response to crises like the pandemic. “Do we need to think at the national level about what we can do to create more surge capacity, to move people when and where they need to go in a crisis? Are there things SHM could do to help?”

Ms. Flores expects more hospital closures than followed the 2008-2009 economic recession, which likely will further drive the trend toward mergers and acquisitions – both of hospitalist groups and of hospitals.

“From the point of view of hospitals, financial pressures will only get worse, pressing us to reinvent how hospitalists work and how that could be made more efficient,” she said. “I hear hospitals saying: ‘We can’t sustain current trends.’ Meanwhile, specialists are saying they need more help from hospitalists, and frontline hospitalists are saying they’re already working too hard. What will we do about burnout?”

These competing trends were all headed toward a perfect storm even before the epidemic hit, Ms. Flores said. “The response will require some innovations we haven’t yet conceived of. Incremental change won’t get us where we need to be. But the hospitalist’s role will be more essential than ever.”

The 2020 data show that a lot of things have been fairly steady for hospitalists, said Thomas Frederickson, MD, a member of SHM’s PAC and a specialist in hospital medicine at CHI Health in Omaha, Neb. But one concern about this stability is that, while hospitalist compensation continues to go up, workload and by extension productivity remain relatively flat. “That has been a trend over the past decade, and some of us find it hard to make sense of that.”

Dr. Frederickson, too, sees a need for disruptive innovation. “I just wish I knew what that will be.” Perhaps, just as hospitalists played a large role in the quality revolution in hospitals over the past decade, maybe in the next decade they will come to play a large role in the right-sizing of hospital care in health systems, he said.

One other important finding: the number of hospitalists per group who play roles as physician leaders has also increased, with an average of 3.2 physicians per group in a formal leadership role (median of 2). But currently, 73% of the highest-ranking leaders in hospitalist groups are male, and they are disproportionally white. As reported in Medscape in 2019, 40% of working hospitalists are women and only 36% of hospitalists overall self-identified as White.¹

“When you think of the demographics of actual working hospitalists, we could say the field of hospital medicine could and should do better in creating opportunities for diversity in leadership roles,” Ms. Flores said.
 

Reference

1. Martin KL. Hospitalist Compensation Report for 2019. Medscape. 2019 Jun 5. https://www.medscape.com/slideshow/2019-compensation-hospitalist-6011429#3.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.