Practice Management

Presenters

Michael Bryant, MD – Children’s Hospital of Los Angeles

Kimberly Manning, MD – Emory University, Atlanta

Kimberly Reynolds, MD – University of Miami

Samir Shah, MD, MSCE, MHM – Cincinnati Children’s Hospital

Ndidi Unaka, MD, MEd – Cincinnati Children’s Hospital

Moderator

Erin Shaughnessy, MD – Phoenix Children’s Hospital

Session summary

This session was devoted to a discussion about how pediatric hospital medicine (PHM) as a field can address racism in medicine. The structural inequity rooted in poverty, housing problems, and differential education represents the essential social determinant of health. No longer can pediatric hospitalists neglect or be in denial of the crucial role that race plays in propagating further inequalities in our society and at our workplace. Historically Black people were exploited in research and still are disproportionately affected when it comes to infant prematurity and mortality, asthma, pain treatments, and so on. The pediatric hospitalist must explore and understand the reasons behind nonadherence and noncompliance among Black patients and always seek to understand before criticizing.

Within learning environments, we must improve how to “autocorrect” and proactively work on our own biases. Dr. Bryant pointed out that each institution has the responsibility to build on the civil rights movement and seize the moment to create a robust response to the inequities manifested during the COVID-19 epidemic, as well as the events following the deaths of George Floyd, Breonna Taylor, Ahmoud Arbery, and many others. Dr. Shah called on the PHM community to take on that obligation by “stepping into the tension,” as Mark Shapiro, MD, has suggested in a conversation/podcast with Dr. Unaka.

As pediatric hospitalists, we will have to show up both individually and as constituents of institutions to address racism by specific projects looking at all data relevant for racism rather than race in quality and safety – thereby amplifying the voices of our Black patients and families, remarked Dr. Unaka. There was a brief reflection on the use of the word “allies” by Dr. Manning and Dr. Reynolds to remind the more than 200 session participants that a bidirectional framework of this process is crucial and that there is a clear need for a partnership to a common goal that should start by “a laydown of privilege of those who have it” to establish equal playing fields once and for all.

Dr. Bryant encouraged a deliberate and early thoughtful process to identify those with opportunities and help young Black people explore journeys in medicine and increase diversity among PHM faculty. Dr. Manning reminded the audience of the power that relationships have and hold in our lives, and not only those of mentors and mentees, but also relationships among all of us as humans. As with those simple situations in which we mess up and have to be able to admit it, apologize for it, and learn to move on, this requires also showing up as a mentee, articulating one’s needs, and learning to break the habits rooted in biases. Dr. Unaka warned against stereotypes and reminded us to look deeper and understand better all of our learners and their blind spots, as well as our own.
 

Key takeaways

• The field of PHM must recognize the role that race plays in propagating inequalities.
• Learning and mentorship environments have to be assessed for the safety of all learners and adjusted to correct (and autocorrect) as many biases as possible.
• Institutions must assume responsibilities to establish a conscious, robust response to injustice and racism in a timely and specific manner.
• Further research efforts must be made to address racism, rather than race.
• The PHM community must show up to create a new, healthy, and deliberate bidirectional framework to endorse and support diversity.

Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork–Presbyterian Morgan Stanley Children’s Hospital, both in New York, with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.

Presenters

Michael Bryant, MD – Children’s Hospital of Los Angeles

Kimberly Manning, MD – Emory University, Atlanta

Kimberly Reynolds, MD – University of Miami

Samir Shah, MD, MSCE, MHM – Cincinnati Children’s Hospital

Ndidi Unaka, MD, MEd – Cincinnati Children’s Hospital

Moderator

Erin Shaughnessy, MD – Phoenix Children’s Hospital

Session summary

This session was devoted to a discussion about how pediatric hospital medicine (PHM) as a field can address racism in medicine. The structural inequity rooted in poverty, housing problems, and differential education represents the essential social determinant of health. No longer can pediatric hospitalists neglect or be in denial of the crucial role that race plays in propagating further inequalities in our society and at our workplace. Historically Black people were exploited in research and still are disproportionately affected when it comes to infant prematurity and mortality, asthma, pain treatments, and so on. The pediatric hospitalist must explore and understand the reasons behind nonadherence and noncompliance among Black patients and always seek to understand before criticizing.

Within learning environments, we must improve how to “autocorrect” and proactively work on our own biases. Dr. Bryant pointed out that each institution has the responsibility to build on the civil rights movement and seize the moment to create a robust response to the inequities manifested during the COVID-19 epidemic, as well as the events following the deaths of George Floyd, Breonna Taylor, Ahmoud Arbery, and many others. Dr. Shah called on the PHM community to take on that obligation by “stepping into the tension,” as Mark Shapiro, MD, has suggested in a conversation/podcast with Dr. Unaka.

As pediatric hospitalists, we will have to show up both individually and as constituents of institutions to address racism by specific projects looking at all data relevant for racism rather than race in quality and safety – thereby amplifying the voices of our Black patients and families, remarked Dr. Unaka. There was a brief reflection on the use of the word “allies” by Dr. Manning and Dr. Reynolds to remind the more than 200 session participants that a bidirectional framework of this process is crucial and that there is a clear need for a partnership to a common goal that should start by “a laydown of privilege of those who have it” to establish equal playing fields once and for all.

Dr. Bryant encouraged a deliberate and early thoughtful process to identify those with opportunities and help young Black people explore journeys in medicine and increase diversity among PHM faculty. Dr. Manning reminded the audience of the power that relationships have and hold in our lives, and not only those of mentors and mentees, but also relationships among all of us as humans. As with those simple situations in which we mess up and have to be able to admit it, apologize for it, and learn to move on, this requires also showing up as a mentee, articulating one’s needs, and learning to break the habits rooted in biases. Dr. Unaka warned against stereotypes and reminded us to look deeper and understand better all of our learners and their blind spots, as well as our own.
 

Key takeaways

• The field of PHM must recognize the role that race plays in propagating inequalities.
• Learning and mentorship environments have to be assessed for the safety of all learners and adjusted to correct (and autocorrect) as many biases as possible.
• Institutions must assume responsibilities to establish a conscious, robust response to injustice and racism in a timely and specific manner.
• Further research efforts must be made to address racism, rather than race.
• The PHM community must show up to create a new, healthy, and deliberate bidirectional framework to endorse and support diversity.

Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork–Presbyterian Morgan Stanley Children’s Hospital, both in New York, with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.

Presenters

Michael Bryant, MD – Children’s Hospital of Los Angeles

Kimberly Manning, MD – Emory University, Atlanta

Kimberly Reynolds, MD – University of Miami

Samir Shah, MD, MSCE, MHM – Cincinnati Children’s Hospital

Ndidi Unaka, MD, MEd – Cincinnati Children’s Hospital

Moderator

Erin Shaughnessy, MD – Phoenix Children’s Hospital

Session summary

This session was devoted to a discussion about how pediatric hospital medicine (PHM) as a field can address racism in medicine. The structural inequity rooted in poverty, housing problems, and differential education represents the essential social determinant of health. No longer can pediatric hospitalists neglect or be in denial of the crucial role that race plays in propagating further inequalities in our society and at our workplace. Historically Black people were exploited in research and still are disproportionately affected when it comes to infant prematurity and mortality, asthma, pain treatments, and so on. The pediatric hospitalist must explore and understand the reasons behind nonadherence and noncompliance among Black patients and always seek to understand before criticizing.

Within learning environments, we must improve how to “autocorrect” and proactively work on our own biases. Dr. Bryant pointed out that each institution has the responsibility to build on the civil rights movement and seize the moment to create a robust response to the inequities manifested during the COVID-19 epidemic, as well as the events following the deaths of George Floyd, Breonna Taylor, Ahmoud Arbery, and many others. Dr. Shah called on the PHM community to take on that obligation by “stepping into the tension,” as Mark Shapiro, MD, has suggested in a conversation/podcast with Dr. Unaka.

As pediatric hospitalists, we will have to show up both individually and as constituents of institutions to address racism by specific projects looking at all data relevant for racism rather than race in quality and safety – thereby amplifying the voices of our Black patients and families, remarked Dr. Unaka. There was a brief reflection on the use of the word “allies” by Dr. Manning and Dr. Reynolds to remind the more than 200 session participants that a bidirectional framework of this process is crucial and that there is a clear need for a partnership to a common goal that should start by “a laydown of privilege of those who have it” to establish equal playing fields once and for all.

Dr. Bryant encouraged a deliberate and early thoughtful process to identify those with opportunities and help young Black people explore journeys in medicine and increase diversity among PHM faculty. Dr. Manning reminded the audience of the power that relationships have and hold in our lives, and not only those of mentors and mentees, but also relationships among all of us as humans. As with those simple situations in which we mess up and have to be able to admit it, apologize for it, and learn to move on, this requires also showing up as a mentee, articulating one’s needs, and learning to break the habits rooted in biases. Dr. Unaka warned against stereotypes and reminded us to look deeper and understand better all of our learners and their blind spots, as well as our own.
 

Key takeaways

• The field of PHM must recognize the role that race plays in propagating inequalities.
• Learning and mentorship environments have to be assessed for the safety of all learners and adjusted to correct (and autocorrect) as many biases as possible.
• Institutions must assume responsibilities to establish a conscious, robust response to injustice and racism in a timely and specific manner.
• Further research efforts must be made to address racism, rather than race.
• The PHM community must show up to create a new, healthy, and deliberate bidirectional framework to endorse and support diversity.

Dr. Giordano is assistant professor of pediatrics at Columbia University and a pediatric hospitalist at NewYork–Presbyterian Morgan Stanley Children’s Hospital, both in New York, with an interest in surgical comanagement. She serves on the Society of Hospital Medicine’s Pediatric Special Interest Group Executive Committee and is the chair of the Education Subcommittee. She is also an advisory board member for the New York/Westchester SHM Chapter.

Hospitalists nationwide have put in longer hours, played new clinical roles, and stretched beyond their medical specialty and comfort level to meet their hospital’s COVID-19 care demands. Can they expect some kind of financial recognition – perhaps in the form of “hazard pay” for going above and beyond – even though their institutions are experiencing negative financial fallout from the crisis?

Hospitals in regions experiencing a COVID-19 surge have limited elective procedures, discouraged non–COVID-19 admissions, and essentially entered crisis management mode. Other facilities in less hard-hit communities are also standing by, with reduced hospital census, smaller caseloads and less work to do, while trying to prepare their bottom lines for lower demand.

“This crisis has put most hospitals in financial jeopardy and that is likely to trickle down to all employees – including hospitalists,” said Ron Greeno, MD, FCCP, MHM, a past president of SHM and the society’s current senior advisor for government affairs. “But it’s not like hospitals could or would forgo an effective hospitalist program today. Hospitalists will be important players in defining the hospital’s future direction post crisis.”

That doesn’t mean tighter financials, caps on annual salary increases, or higher productivity expectations won’t be part of future conversations between hospital administrators and their hospitalists, Dr. Greeno said. Administrators are starting to look ahead to the post–COVID-19 era even as numbers of cases and rates of growth continue to rise in various regions, and Dr. Greeno sees a lot of uncertainty ahead.

Even prior to the crisis, he noted, hospital margins had been falling, while the cost of labor, including hospitalist labor, was going up. That was pointing toward an inevitable collision, which has only intensified with the new financial crisis facing hospitals – created by SARS-CoV-2 and by policies such as shutting down elective surgeries in anticipation of a COVID-19 patient surge that, for some institutions, may never come.

Brian Harte, MD, MHM, president of Cleveland Clinic Akron General and a past president of SHM, said that the Cleveland Clinic system has been planning since January its response to the coming crisis. “Governor Mike DeWine and the state Department of Health led the way in flattening the curve in Ohio. We engaged our hospitalists in brainstorming solutions. They have been excellent partners,” he said.

Approaching the crisis with a sense of urgency from the outset, the Cleveland Clinic built a COVID-19 surge team and incident command structure, with nursing, infectious diseases, critical care and hospital medicine represented. “We used that time to get ready for what was coming. We worked on streamlining consultant work flows.”

But utilization numbers are off in almost every service line, Dr. Harte said. “It has forced us to look at things we’ve always talked about, including greater use of telemedicine and exploring other ways of caring for patients, such as increased use of evening hours.”

Cleveland Clinic contracts with Sound Physicians of Tacoma, Wash., for its hospitalist coverage. “We have an excellent working relationship with Sound at the local, regional, and national levels, with common goals for quality and utilization. We tried to involve our hospitalists as early as possible in planning. We needed them to step in and role model and lead the way,” Dr. Harte said, for everybody’s anxiety levels.

“We’re still in the process of understanding the long-term financial impact of the epidemic,” Dr. Harte added. “But at this point I see no reason to think our relationship with our hospitalists needs to change. We’re the stewards of long-term finances. We’ll need to keep a close eye on this. But we’re committed to working through this together.”

Hazard pay for frontline health care workers was included in the COVID-19 relief package assembled in mid-May by Democrats in the House of Representatives. The $3 trillion HEROES Act includes $200 billion to award hazard pay to essential workers, including those in the health field, but Senate Majority Leader Mitch McConnell (R-Ky.) declared the legislation “dead on arrival” in the Senate.

Supplementary hazard payments made by hospitals to their hospitalists as a reward for sacrifices they made in the crisis is an interesting question, Dr. Greeno noted, and it’s definitely on the table at some hospitals. “But I think it is going to be a tough ask in these times.”

Dr. Harte said he has not offered nor been asked about hazard pay for hospitalists. Cleveland Clinic Akron General made a strategic decision that hazard pay was not going to be part of its response to the pandemic. Other hospital administrators interviewed for this article concur.

Hospitals respond to the fiscal crisis

Hospitals in other parts of the country also report significant fiscal fallout from the COVID-19 crisis, with predictions that 100 or more hospitals may be forced to close. Jeff Dye, president of the New Mexico Hospital Association, told the Albuquerque Journal on May 1 that hospitals in his state have been squeezed on all sides by increased costs, patients delaying routine care, and public health orders restricting elective surgeries. New Mexico hospitals, especially in rural areas, face incredible financial strain.

The University of Virginia Medical Center, Charlottesville, recently announced 20% reductions in total compensation for its providers through July 31, along with suspension of retirement contributions. Those changes won’t affect team members caring for COVID-19 patients. And the Spectrum Health Medical Group of 15 hospitals in western Michigan, according to Michigan Public Radio, told its doctors they either needed to sign “contract addendums” giving the system more control over their hours – or face a 25% pay cut, or worse.

Cheyenne (Wyo.) Regional Medical Center issued a statement April 24 that it expected losses of $10 million for the month of April. “CRMC, like every other hospital in Wyoming, is certainly feeling the financial impact that COVID-19 is having,” CEO Tim Thornell told the Cowboy State Daily on April 24. That includes a 30% reduction in inpatient care and 50% reduction in outpatient care, while the hospital has only had a handful of COVID-19 patients at any time. Capital projects are now on hold, overtime is limited, and a hiring freeze is in effect.

“We’re certainly prepared for a larger surge, which hasn’t come yet,” Mr. Thornell said in an interview. CRMC’s ICU was split to create a nine-bed dedicated COVID-19 unit. Intensivists see most of the critical care patients, while the hospital’s 15 directly-employed hospitalists are treating all of the non-ICU COVID-19 patients. “Among themselves, the hospitalists volunteered who would work on the unit. We’ve been fortunate enough to have enough volunteers and enough PPE [personal protective equipment],” he said.

Preparing for the COVID-19 pandemic has strengthened the medical center’s relationship with its hospitalists, Mr. Thornell explained. “Hospitalists are key to our operations, involved in so much that happens here. We’re trying to staff to volume with decreased utilization. We’ve scaled back, which only makes fiscal sense. Now, how do we reinfuse patients back into the mix? Our hospitalists are paid by the number of shifts, and as you distribute shift reductions over 15 providers, it shouldn’t be an intolerable burden.” But two open hospitalist positions have not been filled, he noted.

CRMC is trying to approach these changes with a Lean perspective, Mr. Thornell said. “We had already adopted a Lean program, but this has been a chance to go through a life-altering circumstance using the tools of Lean planning and applying them instantaneously.”
 

Providers step up

At Emory Healthcare in Atlanta, a major center for COVID-19 cases, communication has been essential in the crisis, said Bryce Gartland, MD, SFHM, Emory’s hospital group president and cochief of clinical operations. “Our group was prepared for a significant influx of patients. Like every other institution, we made the decision to postpone elective care, with a resulting plummet in volume,” he said.

As COVID-19 patients entered the Emory system, frontline hospitalists stepped up to care for those patients. “We’ve had ample providers in terms of clinical care. We guaranteed our physicians’ base compensation. They have flexed teams up and down as needed.” Advanced practice professionals also stepped up to bridge gaps.

With regard to the return of volumes of non–COVID-19 patients, the jury’s still out, Dr. Gartland said. “None of us has a crystal ball, and there are tremendous variables and decision points that will have significant impact. We have started to see numbers of time-sensitive and essential cases increase as of the first week of May.”

What lies ahead will likely include some rightsizing to future volumes. On top of that, the broader economic pressures on hospitals from high rates of unemployment, uninsured patients, bad debt, and charity care will push health care systems to significantly address costs and infrastructure, he said. “We’re still early in planning, and striving to maintain flexibility and nimbleness, given the uncertainties to this early understanding of our new normal. No hospital is immune from the financial impact. We’ll see and hear about more of these conversations in the months ahead.”

But the experience has also generated some positives, Dr. Gartland noted. “Things like telehealth, which we’ve been talking about for years but previously faced barriers to widespread adoption.” Now with COVID-19, the federal government issued waivers, and barriers – both internal and external – came down. “With telehealth, what will the role and deployment of hospitalists look like in this new model? How will traditional productivity expectations change, or the numbers and types of providers? This will make the relationship and partnership between hospitalist groups and hospital administrators ever more important as we consider the evolution toward new care models.”

Dr. Gartland said that “one of the great things about hospital medicine as a field is its flexibility and adaptability. Where there have been gaps, hospitalists were quick to step in. As long as hospital medicine continues to embrace those kinds of behaviors, it will be successful.” But if the conversation with hospitals is just about money, it will be harder, he acknowledged. “Where there is this kind of disruption in our usual way of doing things, there are also tremendous opportunities for care model innovation. I would encourage hospitalist groups to try to be true value partners.”

Command center mode

Like other physicians in hospital C-suites, Chad Whelan MD, FACP, SFHM, chief executive officer of Banner–University Medicine in Tucson, Ariz., led his two hospitals into command center mode when the crisis hit, planning for a surge of COVID-19 cases that could overwhelm hospital capacity.

“In terms of our hospitalists, we leaned in to them hard in the beginning, preparing them to supervise other physicians who came in to help if needed,” he said. “Our [non–COVID-19] census is down, revenues are down, and the implications are enormous – like nothing we’ve ever seen before.”

“We’re fortunate that we’re part of the Banner health system. We made a decision that we would essentially keep our physicians financially protected through this crisis,” Dr. Whelan said. “In return, we called on them to step up and be on the front lines and to put in enormous hours for planning. We asked them to consider: How could you contribute if the surge comes?”

He affirmed that hospital medicine has been a major part of his medical center’s planning and implementation. “I’ve been overwhelmed by the degree to which the entire delivery team has rallied around the pandemic, with everybody saying they want to keep people safe and be part of the solution. We have always had hospitalist leaders at the table as we’ve planned our response and as decisions were made,” said Dr. Whelan, a practicing hospitalist and teaching service attending since 2000 until he assumed his current executive position in Arizona 18 months ago.

“While we have kept people whole during the immediate crisis, we have acknowledged that we don’t know what our recovery will look like. What if [non–COVID-19] volume doesn’t return? That keeps me awake at night,” he said. “I have talked to our physician leadership in hospital medicine and more broadly. We need to ask ourselves many questions, including: do we have the right levels of staffing? Is this the time to consider alternate models of staffing, for example, advanced practice providers? And does the compensation plan need adjustments?”

Dr. Whelan thinks that the COVID-19 crisis is an opportunity for hospital medicine to more rapidly explore different models and to ask what additional value hospitalists can bring to the care model. “For example, what would it mean to redefine the hospitalist’s scope of practice as an acute medicine specialist, not defined by the hospital’s four walls?” he noted.

“One of the reasons our smaller hospital reached capacity with COVID-19 patients was the skilled nursing facility located a few hundred feet away that turned into a hot spot. If we had imported the hospital medicine model virtually into that SNF early on, could there have been a different scenario? Have we thought through what that would have even looked like?” Dr. Whelan asked.

He challenges the hospital medicine field, once it gets to the other side of this crisis, to not fall back on old way of doing things. “Instead, let’s use this time to create a better model today,” he said. “That’s what we’re trying to do at a system level at Banner, with our hospital medicine groups partnering with the hospital. I want to see our hospitalists create and thrive in that new model.”

Hospitalists nationwide have put in longer hours, played new clinical roles, and stretched beyond their medical specialty and comfort level to meet their hospital’s COVID-19 care demands. Can they expect some kind of financial recognition – perhaps in the form of “hazard pay” for going above and beyond – even though their institutions are experiencing negative financial fallout from the crisis?

Hospitals in regions experiencing a COVID-19 surge have limited elective procedures, discouraged non–COVID-19 admissions, and essentially entered crisis management mode. Other facilities in less hard-hit communities are also standing by, with reduced hospital census, smaller caseloads and less work to do, while trying to prepare their bottom lines for lower demand.

“This crisis has put most hospitals in financial jeopardy and that is likely to trickle down to all employees – including hospitalists,” said Ron Greeno, MD, FCCP, MHM, a past president of SHM and the society’s current senior advisor for government affairs. “But it’s not like hospitals could or would forgo an effective hospitalist program today. Hospitalists will be important players in defining the hospital’s future direction post crisis.”

That doesn’t mean tighter financials, caps on annual salary increases, or higher productivity expectations won’t be part of future conversations between hospital administrators and their hospitalists, Dr. Greeno said. Administrators are starting to look ahead to the post–COVID-19 era even as numbers of cases and rates of growth continue to rise in various regions, and Dr. Greeno sees a lot of uncertainty ahead.

Even prior to the crisis, he noted, hospital margins had been falling, while the cost of labor, including hospitalist labor, was going up. That was pointing toward an inevitable collision, which has only intensified with the new financial crisis facing hospitals – created by SARS-CoV-2 and by policies such as shutting down elective surgeries in anticipation of a COVID-19 patient surge that, for some institutions, may never come.

Brian Harte, MD, MHM, president of Cleveland Clinic Akron General and a past president of SHM, said that the Cleveland Clinic system has been planning since January its response to the coming crisis. “Governor Mike DeWine and the state Department of Health led the way in flattening the curve in Ohio. We engaged our hospitalists in brainstorming solutions. They have been excellent partners,” he said.

Approaching the crisis with a sense of urgency from the outset, the Cleveland Clinic built a COVID-19 surge team and incident command structure, with nursing, infectious diseases, critical care and hospital medicine represented. “We used that time to get ready for what was coming. We worked on streamlining consultant work flows.”

But utilization numbers are off in almost every service line, Dr. Harte said. “It has forced us to look at things we’ve always talked about, including greater use of telemedicine and exploring other ways of caring for patients, such as increased use of evening hours.”

Cleveland Clinic contracts with Sound Physicians of Tacoma, Wash., for its hospitalist coverage. “We have an excellent working relationship with Sound at the local, regional, and national levels, with common goals for quality and utilization. We tried to involve our hospitalists as early as possible in planning. We needed them to step in and role model and lead the way,” Dr. Harte said, for everybody’s anxiety levels.

“We’re still in the process of understanding the long-term financial impact of the epidemic,” Dr. Harte added. “But at this point I see no reason to think our relationship with our hospitalists needs to change. We’re the stewards of long-term finances. We’ll need to keep a close eye on this. But we’re committed to working through this together.”

Hazard pay for frontline health care workers was included in the COVID-19 relief package assembled in mid-May by Democrats in the House of Representatives. The $3 trillion HEROES Act includes $200 billion to award hazard pay to essential workers, including those in the health field, but Senate Majority Leader Mitch McConnell (R-Ky.) declared the legislation “dead on arrival” in the Senate.

Supplementary hazard payments made by hospitals to their hospitalists as a reward for sacrifices they made in the crisis is an interesting question, Dr. Greeno noted, and it’s definitely on the table at some hospitals. “But I think it is going to be a tough ask in these times.”

Dr. Harte said he has not offered nor been asked about hazard pay for hospitalists. Cleveland Clinic Akron General made a strategic decision that hazard pay was not going to be part of its response to the pandemic. Other hospital administrators interviewed for this article concur.

Hospitals respond to the fiscal crisis

Hospitals in other parts of the country also report significant fiscal fallout from the COVID-19 crisis, with predictions that 100 or more hospitals may be forced to close. Jeff Dye, president of the New Mexico Hospital Association, told the Albuquerque Journal on May 1 that hospitals in his state have been squeezed on all sides by increased costs, patients delaying routine care, and public health orders restricting elective surgeries. New Mexico hospitals, especially in rural areas, face incredible financial strain.

The University of Virginia Medical Center, Charlottesville, recently announced 20% reductions in total compensation for its providers through July 31, along with suspension of retirement contributions. Those changes won’t affect team members caring for COVID-19 patients. And the Spectrum Health Medical Group of 15 hospitals in western Michigan, according to Michigan Public Radio, told its doctors they either needed to sign “contract addendums” giving the system more control over their hours – or face a 25% pay cut, or worse.

Cheyenne (Wyo.) Regional Medical Center issued a statement April 24 that it expected losses of $10 million for the month of April. “CRMC, like every other hospital in Wyoming, is certainly feeling the financial impact that COVID-19 is having,” CEO Tim Thornell told the Cowboy State Daily on April 24. That includes a 30% reduction in inpatient care and 50% reduction in outpatient care, while the hospital has only had a handful of COVID-19 patients at any time. Capital projects are now on hold, overtime is limited, and a hiring freeze is in effect.

“We’re certainly prepared for a larger surge, which hasn’t come yet,” Mr. Thornell said in an interview. CRMC’s ICU was split to create a nine-bed dedicated COVID-19 unit. Intensivists see most of the critical care patients, while the hospital’s 15 directly-employed hospitalists are treating all of the non-ICU COVID-19 patients. “Among themselves, the hospitalists volunteered who would work on the unit. We’ve been fortunate enough to have enough volunteers and enough PPE [personal protective equipment],” he said.

Preparing for the COVID-19 pandemic has strengthened the medical center’s relationship with its hospitalists, Mr. Thornell explained. “Hospitalists are key to our operations, involved in so much that happens here. We’re trying to staff to volume with decreased utilization. We’ve scaled back, which only makes fiscal sense. Now, how do we reinfuse patients back into the mix? Our hospitalists are paid by the number of shifts, and as you distribute shift reductions over 15 providers, it shouldn’t be an intolerable burden.” But two open hospitalist positions have not been filled, he noted.

CRMC is trying to approach these changes with a Lean perspective, Mr. Thornell said. “We had already adopted a Lean program, but this has been a chance to go through a life-altering circumstance using the tools of Lean planning and applying them instantaneously.”
 

Providers step up

At Emory Healthcare in Atlanta, a major center for COVID-19 cases, communication has been essential in the crisis, said Bryce Gartland, MD, SFHM, Emory’s hospital group president and cochief of clinical operations. “Our group was prepared for a significant influx of patients. Like every other institution, we made the decision to postpone elective care, with a resulting plummet in volume,” he said.

As COVID-19 patients entered the Emory system, frontline hospitalists stepped up to care for those patients. “We’ve had ample providers in terms of clinical care. We guaranteed our physicians’ base compensation. They have flexed teams up and down as needed.” Advanced practice professionals also stepped up to bridge gaps.

With regard to the return of volumes of non–COVID-19 patients, the jury’s still out, Dr. Gartland said. “None of us has a crystal ball, and there are tremendous variables and decision points that will have significant impact. We have started to see numbers of time-sensitive and essential cases increase as of the first week of May.”

What lies ahead will likely include some rightsizing to future volumes. On top of that, the broader economic pressures on hospitals from high rates of unemployment, uninsured patients, bad debt, and charity care will push health care systems to significantly address costs and infrastructure, he said. “We’re still early in planning, and striving to maintain flexibility and nimbleness, given the uncertainties to this early understanding of our new normal. No hospital is immune from the financial impact. We’ll see and hear about more of these conversations in the months ahead.”

But the experience has also generated some positives, Dr. Gartland noted. “Things like telehealth, which we’ve been talking about for years but previously faced barriers to widespread adoption.” Now with COVID-19, the federal government issued waivers, and barriers – both internal and external – came down. “With telehealth, what will the role and deployment of hospitalists look like in this new model? How will traditional productivity expectations change, or the numbers and types of providers? This will make the relationship and partnership between hospitalist groups and hospital administrators ever more important as we consider the evolution toward new care models.”

Dr. Gartland said that “one of the great things about hospital medicine as a field is its flexibility and adaptability. Where there have been gaps, hospitalists were quick to step in. As long as hospital medicine continues to embrace those kinds of behaviors, it will be successful.” But if the conversation with hospitals is just about money, it will be harder, he acknowledged. “Where there is this kind of disruption in our usual way of doing things, there are also tremendous opportunities for care model innovation. I would encourage hospitalist groups to try to be true value partners.”

Command center mode

Like other physicians in hospital C-suites, Chad Whelan MD, FACP, SFHM, chief executive officer of Banner–University Medicine in Tucson, Ariz., led his two hospitals into command center mode when the crisis hit, planning for a surge of COVID-19 cases that could overwhelm hospital capacity.

“In terms of our hospitalists, we leaned in to them hard in the beginning, preparing them to supervise other physicians who came in to help if needed,” he said. “Our [non–COVID-19] census is down, revenues are down, and the implications are enormous – like nothing we’ve ever seen before.”

“We’re fortunate that we’re part of the Banner health system. We made a decision that we would essentially keep our physicians financially protected through this crisis,” Dr. Whelan said. “In return, we called on them to step up and be on the front lines and to put in enormous hours for planning. We asked them to consider: How could you contribute if the surge comes?”

He affirmed that hospital medicine has been a major part of his medical center’s planning and implementation. “I’ve been overwhelmed by the degree to which the entire delivery team has rallied around the pandemic, with everybody saying they want to keep people safe and be part of the solution. We have always had hospitalist leaders at the table as we’ve planned our response and as decisions were made,” said Dr. Whelan, a practicing hospitalist and teaching service attending since 2000 until he assumed his current executive position in Arizona 18 months ago.

“While we have kept people whole during the immediate crisis, we have acknowledged that we don’t know what our recovery will look like. What if [non–COVID-19] volume doesn’t return? That keeps me awake at night,” he said. “I have talked to our physician leadership in hospital medicine and more broadly. We need to ask ourselves many questions, including: do we have the right levels of staffing? Is this the time to consider alternate models of staffing, for example, advanced practice providers? And does the compensation plan need adjustments?”

Dr. Whelan thinks that the COVID-19 crisis is an opportunity for hospital medicine to more rapidly explore different models and to ask what additional value hospitalists can bring to the care model. “For example, what would it mean to redefine the hospitalist’s scope of practice as an acute medicine specialist, not defined by the hospital’s four walls?” he noted.

“One of the reasons our smaller hospital reached capacity with COVID-19 patients was the skilled nursing facility located a few hundred feet away that turned into a hot spot. If we had imported the hospital medicine model virtually into that SNF early on, could there have been a different scenario? Have we thought through what that would have even looked like?” Dr. Whelan asked.

He challenges the hospital medicine field, once it gets to the other side of this crisis, to not fall back on old way of doing things. “Instead, let’s use this time to create a better model today,” he said. “That’s what we’re trying to do at a system level at Banner, with our hospital medicine groups partnering with the hospital. I want to see our hospitalists create and thrive in that new model.”

Hospitalists nationwide have put in longer hours, played new clinical roles, and stretched beyond their medical specialty and comfort level to meet their hospital’s COVID-19 care demands. Can they expect some kind of financial recognition – perhaps in the form of “hazard pay” for going above and beyond – even though their institutions are experiencing negative financial fallout from the crisis?

Hospitals in regions experiencing a COVID-19 surge have limited elective procedures, discouraged non–COVID-19 admissions, and essentially entered crisis management mode. Other facilities in less hard-hit communities are also standing by, with reduced hospital census, smaller caseloads and less work to do, while trying to prepare their bottom lines for lower demand.

“This crisis has put most hospitals in financial jeopardy and that is likely to trickle down to all employees – including hospitalists,” said Ron Greeno, MD, FCCP, MHM, a past president of SHM and the society’s current senior advisor for government affairs. “But it’s not like hospitals could or would forgo an effective hospitalist program today. Hospitalists will be important players in defining the hospital’s future direction post crisis.”

That doesn’t mean tighter financials, caps on annual salary increases, or higher productivity expectations won’t be part of future conversations between hospital administrators and their hospitalists, Dr. Greeno said. Administrators are starting to look ahead to the post–COVID-19 era even as numbers of cases and rates of growth continue to rise in various regions, and Dr. Greeno sees a lot of uncertainty ahead.

Even prior to the crisis, he noted, hospital margins had been falling, while the cost of labor, including hospitalist labor, was going up. That was pointing toward an inevitable collision, which has only intensified with the new financial crisis facing hospitals – created by SARS-CoV-2 and by policies such as shutting down elective surgeries in anticipation of a COVID-19 patient surge that, for some institutions, may never come.

Brian Harte, MD, MHM, president of Cleveland Clinic Akron General and a past president of SHM, said that the Cleveland Clinic system has been planning since January its response to the coming crisis. “Governor Mike DeWine and the state Department of Health led the way in flattening the curve in Ohio. We engaged our hospitalists in brainstorming solutions. They have been excellent partners,” he said.

Approaching the crisis with a sense of urgency from the outset, the Cleveland Clinic built a COVID-19 surge team and incident command structure, with nursing, infectious diseases, critical care and hospital medicine represented. “We used that time to get ready for what was coming. We worked on streamlining consultant work flows.”

But utilization numbers are off in almost every service line, Dr. Harte said. “It has forced us to look at things we’ve always talked about, including greater use of telemedicine and exploring other ways of caring for patients, such as increased use of evening hours.”

Cleveland Clinic contracts with Sound Physicians of Tacoma, Wash., for its hospitalist coverage. “We have an excellent working relationship with Sound at the local, regional, and national levels, with common goals for quality and utilization. We tried to involve our hospitalists as early as possible in planning. We needed them to step in and role model and lead the way,” Dr. Harte said, for everybody’s anxiety levels.

“We’re still in the process of understanding the long-term financial impact of the epidemic,” Dr. Harte added. “But at this point I see no reason to think our relationship with our hospitalists needs to change. We’re the stewards of long-term finances. We’ll need to keep a close eye on this. But we’re committed to working through this together.”

Hazard pay for frontline health care workers was included in the COVID-19 relief package assembled in mid-May by Democrats in the House of Representatives. The $3 trillion HEROES Act includes $200 billion to award hazard pay to essential workers, including those in the health field, but Senate Majority Leader Mitch McConnell (R-Ky.) declared the legislation “dead on arrival” in the Senate.

Supplementary hazard payments made by hospitals to their hospitalists as a reward for sacrifices they made in the crisis is an interesting question, Dr. Greeno noted, and it’s definitely on the table at some hospitals. “But I think it is going to be a tough ask in these times.”

Dr. Harte said he has not offered nor been asked about hazard pay for hospitalists. Cleveland Clinic Akron General made a strategic decision that hazard pay was not going to be part of its response to the pandemic. Other hospital administrators interviewed for this article concur.

Hospitals respond to the fiscal crisis

Hospitals in other parts of the country also report significant fiscal fallout from the COVID-19 crisis, with predictions that 100 or more hospitals may be forced to close. Jeff Dye, president of the New Mexico Hospital Association, told the Albuquerque Journal on May 1 that hospitals in his state have been squeezed on all sides by increased costs, patients delaying routine care, and public health orders restricting elective surgeries. New Mexico hospitals, especially in rural areas, face incredible financial strain.

The University of Virginia Medical Center, Charlottesville, recently announced 20% reductions in total compensation for its providers through July 31, along with suspension of retirement contributions. Those changes won’t affect team members caring for COVID-19 patients. And the Spectrum Health Medical Group of 15 hospitals in western Michigan, according to Michigan Public Radio, told its doctors they either needed to sign “contract addendums” giving the system more control over their hours – or face a 25% pay cut, or worse.

Cheyenne (Wyo.) Regional Medical Center issued a statement April 24 that it expected losses of $10 million for the month of April. “CRMC, like every other hospital in Wyoming, is certainly feeling the financial impact that COVID-19 is having,” CEO Tim Thornell told the Cowboy State Daily on April 24. That includes a 30% reduction in inpatient care and 50% reduction in outpatient care, while the hospital has only had a handful of COVID-19 patients at any time. Capital projects are now on hold, overtime is limited, and a hiring freeze is in effect.

“We’re certainly prepared for a larger surge, which hasn’t come yet,” Mr. Thornell said in an interview. CRMC’s ICU was split to create a nine-bed dedicated COVID-19 unit. Intensivists see most of the critical care patients, while the hospital’s 15 directly-employed hospitalists are treating all of the non-ICU COVID-19 patients. “Among themselves, the hospitalists volunteered who would work on the unit. We’ve been fortunate enough to have enough volunteers and enough PPE [personal protective equipment],” he said.

Preparing for the COVID-19 pandemic has strengthened the medical center’s relationship with its hospitalists, Mr. Thornell explained. “Hospitalists are key to our operations, involved in so much that happens here. We’re trying to staff to volume with decreased utilization. We’ve scaled back, which only makes fiscal sense. Now, how do we reinfuse patients back into the mix? Our hospitalists are paid by the number of shifts, and as you distribute shift reductions over 15 providers, it shouldn’t be an intolerable burden.” But two open hospitalist positions have not been filled, he noted.

CRMC is trying to approach these changes with a Lean perspective, Mr. Thornell said. “We had already adopted a Lean program, but this has been a chance to go through a life-altering circumstance using the tools of Lean planning and applying them instantaneously.”
 

Providers step up

At Emory Healthcare in Atlanta, a major center for COVID-19 cases, communication has been essential in the crisis, said Bryce Gartland, MD, SFHM, Emory’s hospital group president and cochief of clinical operations. “Our group was prepared for a significant influx of patients. Like every other institution, we made the decision to postpone elective care, with a resulting plummet in volume,” he said.

As COVID-19 patients entered the Emory system, frontline hospitalists stepped up to care for those patients. “We’ve had ample providers in terms of clinical care. We guaranteed our physicians’ base compensation. They have flexed teams up and down as needed.” Advanced practice professionals also stepped up to bridge gaps.

With regard to the return of volumes of non–COVID-19 patients, the jury’s still out, Dr. Gartland said. “None of us has a crystal ball, and there are tremendous variables and decision points that will have significant impact. We have started to see numbers of time-sensitive and essential cases increase as of the first week of May.”

What lies ahead will likely include some rightsizing to future volumes. On top of that, the broader economic pressures on hospitals from high rates of unemployment, uninsured patients, bad debt, and charity care will push health care systems to significantly address costs and infrastructure, he said. “We’re still early in planning, and striving to maintain flexibility and nimbleness, given the uncertainties to this early understanding of our new normal. No hospital is immune from the financial impact. We’ll see and hear about more of these conversations in the months ahead.”

But the experience has also generated some positives, Dr. Gartland noted. “Things like telehealth, which we’ve been talking about for years but previously faced barriers to widespread adoption.” Now with COVID-19, the federal government issued waivers, and barriers – both internal and external – came down. “With telehealth, what will the role and deployment of hospitalists look like in this new model? How will traditional productivity expectations change, or the numbers and types of providers? This will make the relationship and partnership between hospitalist groups and hospital administrators ever more important as we consider the evolution toward new care models.”

Dr. Gartland said that “one of the great things about hospital medicine as a field is its flexibility and adaptability. Where there have been gaps, hospitalists were quick to step in. As long as hospital medicine continues to embrace those kinds of behaviors, it will be successful.” But if the conversation with hospitals is just about money, it will be harder, he acknowledged. “Where there is this kind of disruption in our usual way of doing things, there are also tremendous opportunities for care model innovation. I would encourage hospitalist groups to try to be true value partners.”

Command center mode

Like other physicians in hospital C-suites, Chad Whelan MD, FACP, SFHM, chief executive officer of Banner–University Medicine in Tucson, Ariz., led his two hospitals into command center mode when the crisis hit, planning for a surge of COVID-19 cases that could overwhelm hospital capacity.

“In terms of our hospitalists, we leaned in to them hard in the beginning, preparing them to supervise other physicians who came in to help if needed,” he said. “Our [non–COVID-19] census is down, revenues are down, and the implications are enormous – like nothing we’ve ever seen before.”

“We’re fortunate that we’re part of the Banner health system. We made a decision that we would essentially keep our physicians financially protected through this crisis,” Dr. Whelan said. “In return, we called on them to step up and be on the front lines and to put in enormous hours for planning. We asked them to consider: How could you contribute if the surge comes?”

He affirmed that hospital medicine has been a major part of his medical center’s planning and implementation. “I’ve been overwhelmed by the degree to which the entire delivery team has rallied around the pandemic, with everybody saying they want to keep people safe and be part of the solution. We have always had hospitalist leaders at the table as we’ve planned our response and as decisions were made,” said Dr. Whelan, a practicing hospitalist and teaching service attending since 2000 until he assumed his current executive position in Arizona 18 months ago.

“While we have kept people whole during the immediate crisis, we have acknowledged that we don’t know what our recovery will look like. What if [non–COVID-19] volume doesn’t return? That keeps me awake at night,” he said. “I have talked to our physician leadership in hospital medicine and more broadly. We need to ask ourselves many questions, including: do we have the right levels of staffing? Is this the time to consider alternate models of staffing, for example, advanced practice providers? And does the compensation plan need adjustments?”

Dr. Whelan thinks that the COVID-19 crisis is an opportunity for hospital medicine to more rapidly explore different models and to ask what additional value hospitalists can bring to the care model. “For example, what would it mean to redefine the hospitalist’s scope of practice as an acute medicine specialist, not defined by the hospital’s four walls?” he noted.

“One of the reasons our smaller hospital reached capacity with COVID-19 patients was the skilled nursing facility located a few hundred feet away that turned into a hot spot. If we had imported the hospital medicine model virtually into that SNF early on, could there have been a different scenario? Have we thought through what that would have even looked like?” Dr. Whelan asked.

He challenges the hospital medicine field, once it gets to the other side of this crisis, to not fall back on old way of doing things. “Instead, let’s use this time to create a better model today,” he said. “That’s what we’re trying to do at a system level at Banner, with our hospital medicine groups partnering with the hospital. I want to see our hospitalists create and thrive in that new model.”

Most residents who were asked whether their training prepared them for COVID-19 in a Medscape survey said it had not or they weren’t sure.

Whereas 40% said they felt prepared, 30% said they did not feel prepared and 31% answered they were unsure. (Numbers were rounded, so some answers pushed above 100%.)

One quarter have $300,000 or more in student debt

The Medscape Residents Salary & Debt Report 2020, with data collected April 3 to June 1, found that nearly one in four residents (24%) had medical school debt of more than $300,000. Half (49%) had more than $200,000.

The data include answers from 1,659 U.S. medical residents.

For the sixth straight year, female residents were more satisfied with their pay than were their male colleagues. This year the satisfaction gap was 45% female compared with 42% male. That imbalance came despite their making nearly the same pay overall ($63,700 for men and $63,000 for women).

Among practicing physicians, the pay gap is much wider: Men make 25% more in primary care and 31% more in specialties.

More than a third of residents (34%) said they felt residents should make 26%-50% more than they do. Ten percent thought they should earn 76%-100% more.

For those not satisfied with pay, the top reasons were feeling the pay was too low for the hours worked (81%) or too low compared with other medical staff, such as physician assistants (PAs) or nurses (77% chose that answer).

As for hours worked, 31% of residents reported they spend more than 60 hours/week seeing patients.

The top-paying specialties, averaging $69,500, were allergy and immunology, hematology, plastic surgery, aesthetic medicine, rheumatology, and specialized surgery. The lowest paid were family medicine residents at $58,500.

In primary care, overall, most residents said they planned to specialize. Only 47% planned to continue to work in primary care. Male residents were much more likely to say they will subspecialize than were their female colleagues (52% vs. 35%).

More than 90% of residents say future pay has influenced their choice of specialty, though more men than women felt that way (93% vs. 86%).

Good relationships with others

Overall, residents reported good relationships with attending physicians and nurses.

Most (88%) said they had good or very good relationships with attending physicians, 10% said the relationships were fair, and 2% said they were poor.

In addition, 89% of residents said the amount of supervision was appropriate, 4% said there was too much, and 7% said there was too little.

Relationships with nurses/PAs were slightly less positive overall: Eighty-two percent reported good or very good relationships with nurses/PAs, 15% said those relationships were fair, and 3% said they were poor.

One respondent said: “Our relationships could be better, but I think everyone is just overwhelmed with COVID-19, so emotions are heightened.”

Another said: “It takes time to earn the respect from nurses.”

Seventy-seven percent said they were satisfied with their learning experience overall, 12% were neutral on the question, and 11% said they were dissatisfied or very dissatisfied.

Work-life balance is the top concern

Work-life balance continues to be the top concern for residents. More than one-quarter (27%) in residency years 1 through 4 listed that as the top concern, and even more (32%) of those in years 5 through 8 agreed.

That was followed by demands on time and fear of failure or making a serious mistake.

The survey indicates that benefit packages for residents have stayed much the same over the past 2 years with health insurance and paid time off for sick leave, vacation, and personal time most commonly reported at 89% and 87%, respectively.

Much less common were benefits including commuter assistance (parking, public transportation) at 24%, housing allowance (8%), and child care (4%).

The vast majority of residents reported doing scut work (unskilled tasks): More than half (54%) reported doing 1-10 hours/week and 22% did 11-20 hours/week. Regardless of the number of hours, however, 62% said the time spent performing these tasks was appropriate.
 

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

Most residents who were asked whether their training prepared them for COVID-19 in a Medscape survey said it had not or they weren’t sure.

Whereas 40% said they felt prepared, 30% said they did not feel prepared and 31% answered they were unsure. (Numbers were rounded, so some answers pushed above 100%.)

One quarter have $300,000 or more in student debt

The Medscape Residents Salary & Debt Report 2020, with data collected April 3 to June 1, found that nearly one in four residents (24%) had medical school debt of more than $300,000. Half (49%) had more than $200,000.

The data include answers from 1,659 U.S. medical residents.

For the sixth straight year, female residents were more satisfied with their pay than were their male colleagues. This year the satisfaction gap was 45% female compared with 42% male. That imbalance came despite their making nearly the same pay overall ($63,700 for men and $63,000 for women).

Among practicing physicians, the pay gap is much wider: Men make 25% more in primary care and 31% more in specialties.

More than a third of residents (34%) said they felt residents should make 26%-50% more than they do. Ten percent thought they should earn 76%-100% more.

For those not satisfied with pay, the top reasons were feeling the pay was too low for the hours worked (81%) or too low compared with other medical staff, such as physician assistants (PAs) or nurses (77% chose that answer).

As for hours worked, 31% of residents reported they spend more than 60 hours/week seeing patients.

The top-paying specialties, averaging $69,500, were allergy and immunology, hematology, plastic surgery, aesthetic medicine, rheumatology, and specialized surgery. The lowest paid were family medicine residents at $58,500.

In primary care, overall, most residents said they planned to specialize. Only 47% planned to continue to work in primary care. Male residents were much more likely to say they will subspecialize than were their female colleagues (52% vs. 35%).

More than 90% of residents say future pay has influenced their choice of specialty, though more men than women felt that way (93% vs. 86%).

Good relationships with others

Overall, residents reported good relationships with attending physicians and nurses.

Most (88%) said they had good or very good relationships with attending physicians, 10% said the relationships were fair, and 2% said they were poor.

In addition, 89% of residents said the amount of supervision was appropriate, 4% said there was too much, and 7% said there was too little.

Relationships with nurses/PAs were slightly less positive overall: Eighty-two percent reported good or very good relationships with nurses/PAs, 15% said those relationships were fair, and 3% said they were poor.

One respondent said: “Our relationships could be better, but I think everyone is just overwhelmed with COVID-19, so emotions are heightened.”

Another said: “It takes time to earn the respect from nurses.”

Seventy-seven percent said they were satisfied with their learning experience overall, 12% were neutral on the question, and 11% said they were dissatisfied or very dissatisfied.

Work-life balance is the top concern

Work-life balance continues to be the top concern for residents. More than one-quarter (27%) in residency years 1 through 4 listed that as the top concern, and even more (32%) of those in years 5 through 8 agreed.

That was followed by demands on time and fear of failure or making a serious mistake.

The survey indicates that benefit packages for residents have stayed much the same over the past 2 years with health insurance and paid time off for sick leave, vacation, and personal time most commonly reported at 89% and 87%, respectively.

Much less common were benefits including commuter assistance (parking, public transportation) at 24%, housing allowance (8%), and child care (4%).

The vast majority of residents reported doing scut work (unskilled tasks): More than half (54%) reported doing 1-10 hours/week and 22% did 11-20 hours/week. Regardless of the number of hours, however, 62% said the time spent performing these tasks was appropriate.
 

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

Most residents who were asked whether their training prepared them for COVID-19 in a Medscape survey said it had not or they weren’t sure.

Whereas 40% said they felt prepared, 30% said they did not feel prepared and 31% answered they were unsure. (Numbers were rounded, so some answers pushed above 100%.)

One quarter have $300,000 or more in student debt

The Medscape Residents Salary & Debt Report 2020, with data collected April 3 to June 1, found that nearly one in four residents (24%) had medical school debt of more than $300,000. Half (49%) had more than $200,000.

The data include answers from 1,659 U.S. medical residents.

For the sixth straight year, female residents were more satisfied with their pay than were their male colleagues. This year the satisfaction gap was 45% female compared with 42% male. That imbalance came despite their making nearly the same pay overall ($63,700 for men and $63,000 for women).

Among practicing physicians, the pay gap is much wider: Men make 25% more in primary care and 31% more in specialties.

More than a third of residents (34%) said they felt residents should make 26%-50% more than they do. Ten percent thought they should earn 76%-100% more.

For those not satisfied with pay, the top reasons were feeling the pay was too low for the hours worked (81%) or too low compared with other medical staff, such as physician assistants (PAs) or nurses (77% chose that answer).

As for hours worked, 31% of residents reported they spend more than 60 hours/week seeing patients.

The top-paying specialties, averaging $69,500, were allergy and immunology, hematology, plastic surgery, aesthetic medicine, rheumatology, and specialized surgery. The lowest paid were family medicine residents at $58,500.

In primary care, overall, most residents said they planned to specialize. Only 47% planned to continue to work in primary care. Male residents were much more likely to say they will subspecialize than were their female colleagues (52% vs. 35%).

More than 90% of residents say future pay has influenced their choice of specialty, though more men than women felt that way (93% vs. 86%).

Good relationships with others

Overall, residents reported good relationships with attending physicians and nurses.

Most (88%) said they had good or very good relationships with attending physicians, 10% said the relationships were fair, and 2% said they were poor.

In addition, 89% of residents said the amount of supervision was appropriate, 4% said there was too much, and 7% said there was too little.

Relationships with nurses/PAs were slightly less positive overall: Eighty-two percent reported good or very good relationships with nurses/PAs, 15% said those relationships were fair, and 3% said they were poor.

One respondent said: “Our relationships could be better, but I think everyone is just overwhelmed with COVID-19, so emotions are heightened.”

Another said: “It takes time to earn the respect from nurses.”

Seventy-seven percent said they were satisfied with their learning experience overall, 12% were neutral on the question, and 11% said they were dissatisfied or very dissatisfied.

Work-life balance is the top concern

Work-life balance continues to be the top concern for residents. More than one-quarter (27%) in residency years 1 through 4 listed that as the top concern, and even more (32%) of those in years 5 through 8 agreed.

That was followed by demands on time and fear of failure or making a serious mistake.

The survey indicates that benefit packages for residents have stayed much the same over the past 2 years with health insurance and paid time off for sick leave, vacation, and personal time most commonly reported at 89% and 87%, respectively.

Much less common were benefits including commuter assistance (parking, public transportation) at 24%, housing allowance (8%), and child care (4%).

The vast majority of residents reported doing scut work (unskilled tasks): More than half (54%) reported doing 1-10 hours/week and 22% did 11-20 hours/week. Regardless of the number of hours, however, 62% said the time spent performing these tasks was appropriate.
 

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

One of the most significant shifts in hospital practice over recent decades has been the widespread adoption of electronic medical records as a replacement for conventional paper records.

While EMRs show a lot of promise – having the potential to centralize and simplify clinician notes, make information more accessible and reduce paper waste – there is strong evidence that they are not working as well as they could.

Some research suggests that these systems may decrease the working efficiency of clinicians. Now, major health care institutions are looking to understand why these systems are not working — as well as how they may be improved.

A recent white paper from the Society of Hospital Medicine’s Healthcare Information Technology Special Interest Group – titled “More Caring, Less Clicking” – reviews the current shortcomings of EMRs from a hospitalist perspective and provides recommendations for how these systems can be made more workable and efficient.

The current state of EMRs

“Numerous previous papers – including SHM’s 2017 white paper ‘Hospitalist Perspectives on Electronic Medical Records’ – have linked EMRs to decreased provider satisfaction and increased burnout related to multiple issues, including an increase in ‘screen time’ as opposed to patient ‘face-to-face’ time, and limitations in usability and interoperability,” said Rupesh Prasad, MD, SFHM, medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. “Studies have shown that most of a provider’s time spent is in areas like clinical documentation, entry of orders, and accessing patient information.”

The 2017 SHM white paper referenced by Dr. Prasad reported that 74% of hospitalists surveyed were dissatisfied with their EMR. A full one-quarter of surveyed physicians went so far as saying they would prefer switching to paper record keeping.

Other research has also found a possible link between EMRs and physician burnout and dissatisfaction. It is also not uncommon for hospitalists to spend up to 25% of their time at work using their EMR – time that should, ideally, be spent with patients.

The 2017 paper also showed that clinician notes in the United States are four times longer, on average, than notes in other countries. There are a few reasons for this – including technology design and billing requirements encouraging longer notes. Whatever the cause, however, longer notes linked to physician burnout may be partially responsible for the large amounts of time physicians spend looking at EMRs.

While EMRs may hold significant potential for hospitalists, as they are designed currently, they are simply not delivering the value many expected. The new white paper from the Healthcare Information Technology Special Interest Group outlines practical changes that could be made to EMRs to improve their use in hospitals.

The paper breaks down current issues with EMRs into five broad categories – documentation, clinical decision support, order entry, communication, and data review – to discuss how EMRs are currently failing in these areas as well as how they might be improved.

Improving EMR documentation

One of the most significant hurdles clinicians currently face lies in how EMRs currently store and display documentation. Combined with physician note-taking habits, this makes these systems much less usable than they could be. Longer notes, when displayed in current EMR UIs, mostly lead to clutter, making them harder to navigate and difficult to scan quickly for important information.

The authors identify a few different ways that future EMRs may be able to help with this problem.

EMR documentation tools will likely need to be redesigned to optimize documentation entry, standardize note formatting, and improve readability. Many electronic notes contain vestigial formatting and data left over from the design of paper notes. As a result, many of these electronic notes include information that is stored elsewhere and does not need to be explicitly included in every note. Cutting down on repetitive information storage will make important information more visible and help make patient notes easier to scan.

The paper also recommends a few other features that would make documentation more readable – like allowing clinicians to write documentation in SOAP format (subjective, objective, assessment, and plan), to facilitate critical thinking during the note-taking process, and having the EMR display that documentation in APSO format (assessment, plan, subjective, objective).

Doctors have long called for APSO or another note-taking format to replace SOAP in EMRs. Designing EMRs to rearrange SOAP notes to APSO could be a compromise that improves note readability while not requiring that clinicians learn new note-taking strategies.

The paper’s authors also recommended more extensive clinician training on writing notes. While clinicians are often taught how to write certain notes – like progress notes, histories, and physical and discharge summaries – more specific guidance is not always provided. Better training provided by institutions could help improve the quality and readability of clinician notes.

These changes, however, may not be as beneficial as possible without better institutional support for clinicians. Implementing some of the biggest changes recommended by the SHM will require some level of standardization across platforms and institution commitment to training clinicians on best use practices for EMRs. Improved responsiveness to clinician needs will require a coordinated effort with backing from both administrative and governance groups.

Expanding EMR usability

“Our white paper presents evidence-based recommendations that can be implemented at the ground level in collaboration with other stakeholders, including IT, informatics, and administration, to help improve on the current state,” Dr. Prasad said.

“We believe that hospitalists as key stakeholders in health care, have both the responsibility and are uniquely positioned to directly impact EMR functionality,” he noted. “For example, hospitalists can participate in designing appropriate, actionable alerts that would help with patient safety while also improving provider efficiency. Simple steps like limiting hard stops in order entry to would help speed up the process, and free up time for direct patient care. Availability of tools like secure text messaging would help with effective patient care team communication to improve safety and care delivery.”

EMRs often lack features like voice control and speech-to-text transcription, along with other basic accessibility features like compatibility with screen readers. Implementing these features could improve the efficiency of clinicians’ note-taking while also providing wider software usability.

EMRs are not typically designed to work with mobile devices, meaning clinicians cannot enter notes or order medications until they’ve returned to their desk or workstation.

This lack of functionality creates issues in several ways. When clinicians are unable to enter notes on the move, they will need to either keep mental notes or quickly jot down paper notes. This can effectively double the amount of note-taking that clinicians must do or introduce greater room for error. In cases where progress notes are taken throughout the day, this also means the EMR’s documentation timeline may not be accurate or usable.

Requiring clinicians to return to workstations before entering order information can also increase the risk of medication errors, which remains high despite hopes that EMRs could reduce error rates.

Adding support for cross-device and mobile EMR use could help improve the efficiency of note-taking and help cut down on error. Implementing mobile access could have a few different benefits for clinicians – like improving note-taking efficiency in hospitals, where doctors often see patients far away from their workstations.

EMRs also often lack support for certain hardware, like mobile stations and widescreen monitors, which can improve a clinician’s ability to document in real-time and are a better fit in certain work flows.

The SHM paper also recommends a few other tweaks to usability – like reducing the amount of password entry and reentry – that could make these systems easier to use and more efficient.

New features – like the use of natural language processing technology to analyze and organize information contained in clinicians’ notes – could provide further benefits and take full advantage of the advanced technologies that EMRs can integrate.

Dr. Prasad noted, however, that some of these upgrades – especially EMR compatibility with mobile devices – will require some institutional support. Bring-your-own-device policies or system-provided mobile devices will be necessary if institutions want their clinicians to be able to take advantage of mobile EMR access.

These policies will also likely require some kind of mobile device management solution to manage the security of sensitive patient data as it is accessed from personal devices. This may increase the level of necessary institutional buy-in for this support to work.

Designing EMRs with clinician needs in mind

Dr. Prasad said he and his coauthors recommend that EMR developers base more of their design on the needs of clinicians.

Currently, EMR interfaces can make important data unavailable, depending on what a clinician is trying to do. As a result, clinicians often need to rely on mental recall of important information as they navigate EMR systems.

These interfaces also typically do not support any level of user customization or process-specific interfaces, meaning every clinician is working with the same interface regardless of the tasks they need to perform or the information they need access to. Allowing for customization or implementing new process- or disease-specific interfaces could help avoid some of the problems caused by one-size-fits-all interfaces, which are not necessarily compatible with every clinician work flow.

EMR interfaces should also be designed, wherever possible, with familiar or standardized formats and the use of color coding and other techniques that can make interfaces easier to navigate quickly. Right now, many EMR systems utilize inconsistent layout design that can be cluttered with irrelevant information, slowing down interface navigation and sometimes requiring backtracking from clinicians.

Ideally, this will improve the speed of information gathering and data review, reducing the amount of time clinicians need to spend working with their EMR.

The white paper also recommends that EMR designers improve alert systems so that they are more actionable and interrupt clinicians less often – and that, when they do, they ensure that clinicians can respond to them. Designers should also reduce hard-stops or in-line alerts that halt clinicians’ work flows and require immediate responses where possible.

Increased EMR support for clinical decision support systems is one of the biggest health care trends expected to be seen throughout this decade. However, many clinicians are disappointed with the lack of flexibility and optimization of the current alerts that CDS provides. Updating and improving these knowledge-based systems will likely become essential for delivering better alerts and improving decision-making and efficiency.

Overall, EMR design should be informed by the needs of the people these products are designed to support, Dr. Prasad said. The people that work with EMRs – especially frontline staff like providers, nurses, and pharmacists that regularly interact with EMRs to provide care – should be involved early on in the EMR design process. Right now, their needs are not reflected in current EMR design. EMR companies, by working with these hospital staff members, could help improve ease of use and, ideally, prevent some of the errors associated with the current implementation of these systems.

“System designers should be able to avoid some of the most common problems of EMRs – and predict potential problems – by consistently soliciting and integrating clinician feedback during the design process and over the lifespan of a product,” Dr. Prasad said.

How EMRs can be improved

Over the past few years, EMRs have become quickly adopted by health care professionals and institutions. However, despite hopes that EMRs could significantly improve record keeping and note-taking, these systems continue to pose serious challenges for the clinicians who use them. Evidence from recent research suggests that these systems are inefficient and may contribute to physician burnout.

As a result, organizations like SHM are looking for ways that these systems can be improved.

“The growth of health IT has led to availability of large amounts of data and opportunities for applications in [artificial intelligence and machine learning,” Dr. Prasad noted. “While this has opened many avenues to help positively impact patient care and outcomes, it also poses multiple challenges like validation, customization, and governance. Hospitalists can partner with other health professions and IT leaders to work toward the common goal of improving the health of the population while also providing a positive experience to the end user.”

Another problem with current EMRs is their lack of flexibility. These systems are often not compatible with mobile devices and certain types of hardware and may be difficult or impossible to customize. They also frequently require unnecessary information during the note-taking process that results in cluttered and difficult-to-scan documentation. Improving EMR flexibility – and inviting clinicians to consult during the design process – could solve many of these problems.

New technological developments may also soon help developers improve their EMRs. In the future, as technology like natural language processing becomes more advanced and more commonly used, they may be able to make EMRs even more efficient and user friendly.

One of the most significant shifts in hospital practice over recent decades has been the widespread adoption of electronic medical records as a replacement for conventional paper records.

While EMRs show a lot of promise – having the potential to centralize and simplify clinician notes, make information more accessible and reduce paper waste – there is strong evidence that they are not working as well as they could.

Some research suggests that these systems may decrease the working efficiency of clinicians. Now, major health care institutions are looking to understand why these systems are not working — as well as how they may be improved.

A recent white paper from the Society of Hospital Medicine’s Healthcare Information Technology Special Interest Group – titled “More Caring, Less Clicking” – reviews the current shortcomings of EMRs from a hospitalist perspective and provides recommendations for how these systems can be made more workable and efficient.

The current state of EMRs

“Numerous previous papers – including SHM’s 2017 white paper ‘Hospitalist Perspectives on Electronic Medical Records’ – have linked EMRs to decreased provider satisfaction and increased burnout related to multiple issues, including an increase in ‘screen time’ as opposed to patient ‘face-to-face’ time, and limitations in usability and interoperability,” said Rupesh Prasad, MD, SFHM, medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. “Studies have shown that most of a provider’s time spent is in areas like clinical documentation, entry of orders, and accessing patient information.”

The 2017 SHM white paper referenced by Dr. Prasad reported that 74% of hospitalists surveyed were dissatisfied with their EMR. A full one-quarter of surveyed physicians went so far as saying they would prefer switching to paper record keeping.

Other research has also found a possible link between EMRs and physician burnout and dissatisfaction. It is also not uncommon for hospitalists to spend up to 25% of their time at work using their EMR – time that should, ideally, be spent with patients.

The 2017 paper also showed that clinician notes in the United States are four times longer, on average, than notes in other countries. There are a few reasons for this – including technology design and billing requirements encouraging longer notes. Whatever the cause, however, longer notes linked to physician burnout may be partially responsible for the large amounts of time physicians spend looking at EMRs.

While EMRs may hold significant potential for hospitalists, as they are designed currently, they are simply not delivering the value many expected. The new white paper from the Healthcare Information Technology Special Interest Group outlines practical changes that could be made to EMRs to improve their use in hospitals.

The paper breaks down current issues with EMRs into five broad categories – documentation, clinical decision support, order entry, communication, and data review – to discuss how EMRs are currently failing in these areas as well as how they might be improved.

Improving EMR documentation

One of the most significant hurdles clinicians currently face lies in how EMRs currently store and display documentation. Combined with physician note-taking habits, this makes these systems much less usable than they could be. Longer notes, when displayed in current EMR UIs, mostly lead to clutter, making them harder to navigate and difficult to scan quickly for important information.

The authors identify a few different ways that future EMRs may be able to help with this problem.

EMR documentation tools will likely need to be redesigned to optimize documentation entry, standardize note formatting, and improve readability. Many electronic notes contain vestigial formatting and data left over from the design of paper notes. As a result, many of these electronic notes include information that is stored elsewhere and does not need to be explicitly included in every note. Cutting down on repetitive information storage will make important information more visible and help make patient notes easier to scan.

The paper also recommends a few other features that would make documentation more readable – like allowing clinicians to write documentation in SOAP format (subjective, objective, assessment, and plan), to facilitate critical thinking during the note-taking process, and having the EMR display that documentation in APSO format (assessment, plan, subjective, objective).

Doctors have long called for APSO or another note-taking format to replace SOAP in EMRs. Designing EMRs to rearrange SOAP notes to APSO could be a compromise that improves note readability while not requiring that clinicians learn new note-taking strategies.

The paper’s authors also recommended more extensive clinician training on writing notes. While clinicians are often taught how to write certain notes – like progress notes, histories, and physical and discharge summaries – more specific guidance is not always provided. Better training provided by institutions could help improve the quality and readability of clinician notes.

These changes, however, may not be as beneficial as possible without better institutional support for clinicians. Implementing some of the biggest changes recommended by the SHM will require some level of standardization across platforms and institution commitment to training clinicians on best use practices for EMRs. Improved responsiveness to clinician needs will require a coordinated effort with backing from both administrative and governance groups.

Expanding EMR usability

“Our white paper presents evidence-based recommendations that can be implemented at the ground level in collaboration with other stakeholders, including IT, informatics, and administration, to help improve on the current state,” Dr. Prasad said.

“We believe that hospitalists as key stakeholders in health care, have both the responsibility and are uniquely positioned to directly impact EMR functionality,” he noted. “For example, hospitalists can participate in designing appropriate, actionable alerts that would help with patient safety while also improving provider efficiency. Simple steps like limiting hard stops in order entry to would help speed up the process, and free up time for direct patient care. Availability of tools like secure text messaging would help with effective patient care team communication to improve safety and care delivery.”

EMRs often lack features like voice control and speech-to-text transcription, along with other basic accessibility features like compatibility with screen readers. Implementing these features could improve the efficiency of clinicians’ note-taking while also providing wider software usability.

EMRs are not typically designed to work with mobile devices, meaning clinicians cannot enter notes or order medications until they’ve returned to their desk or workstation.

This lack of functionality creates issues in several ways. When clinicians are unable to enter notes on the move, they will need to either keep mental notes or quickly jot down paper notes. This can effectively double the amount of note-taking that clinicians must do or introduce greater room for error. In cases where progress notes are taken throughout the day, this also means the EMR’s documentation timeline may not be accurate or usable.

Requiring clinicians to return to workstations before entering order information can also increase the risk of medication errors, which remains high despite hopes that EMRs could reduce error rates.

Adding support for cross-device and mobile EMR use could help improve the efficiency of note-taking and help cut down on error. Implementing mobile access could have a few different benefits for clinicians – like improving note-taking efficiency in hospitals, where doctors often see patients far away from their workstations.

EMRs also often lack support for certain hardware, like mobile stations and widescreen monitors, which can improve a clinician’s ability to document in real-time and are a better fit in certain work flows.

The SHM paper also recommends a few other tweaks to usability – like reducing the amount of password entry and reentry – that could make these systems easier to use and more efficient.

New features – like the use of natural language processing technology to analyze and organize information contained in clinicians’ notes – could provide further benefits and take full advantage of the advanced technologies that EMRs can integrate.

Dr. Prasad noted, however, that some of these upgrades – especially EMR compatibility with mobile devices – will require some institutional support. Bring-your-own-device policies or system-provided mobile devices will be necessary if institutions want their clinicians to be able to take advantage of mobile EMR access.

These policies will also likely require some kind of mobile device management solution to manage the security of sensitive patient data as it is accessed from personal devices. This may increase the level of necessary institutional buy-in for this support to work.

Designing EMRs with clinician needs in mind

Dr. Prasad said he and his coauthors recommend that EMR developers base more of their design on the needs of clinicians.

Currently, EMR interfaces can make important data unavailable, depending on what a clinician is trying to do. As a result, clinicians often need to rely on mental recall of important information as they navigate EMR systems.

These interfaces also typically do not support any level of user customization or process-specific interfaces, meaning every clinician is working with the same interface regardless of the tasks they need to perform or the information they need access to. Allowing for customization or implementing new process- or disease-specific interfaces could help avoid some of the problems caused by one-size-fits-all interfaces, which are not necessarily compatible with every clinician work flow.

EMR interfaces should also be designed, wherever possible, with familiar or standardized formats and the use of color coding and other techniques that can make interfaces easier to navigate quickly. Right now, many EMR systems utilize inconsistent layout design that can be cluttered with irrelevant information, slowing down interface navigation and sometimes requiring backtracking from clinicians.

Ideally, this will improve the speed of information gathering and data review, reducing the amount of time clinicians need to spend working with their EMR.

The white paper also recommends that EMR designers improve alert systems so that they are more actionable and interrupt clinicians less often – and that, when they do, they ensure that clinicians can respond to them. Designers should also reduce hard-stops or in-line alerts that halt clinicians’ work flows and require immediate responses where possible.

Increased EMR support for clinical decision support systems is one of the biggest health care trends expected to be seen throughout this decade. However, many clinicians are disappointed with the lack of flexibility and optimization of the current alerts that CDS provides. Updating and improving these knowledge-based systems will likely become essential for delivering better alerts and improving decision-making and efficiency.

Overall, EMR design should be informed by the needs of the people these products are designed to support, Dr. Prasad said. The people that work with EMRs – especially frontline staff like providers, nurses, and pharmacists that regularly interact with EMRs to provide care – should be involved early on in the EMR design process. Right now, their needs are not reflected in current EMR design. EMR companies, by working with these hospital staff members, could help improve ease of use and, ideally, prevent some of the errors associated with the current implementation of these systems.

“System designers should be able to avoid some of the most common problems of EMRs – and predict potential problems – by consistently soliciting and integrating clinician feedback during the design process and over the lifespan of a product,” Dr. Prasad said.

How EMRs can be improved

Over the past few years, EMRs have become quickly adopted by health care professionals and institutions. However, despite hopes that EMRs could significantly improve record keeping and note-taking, these systems continue to pose serious challenges for the clinicians who use them. Evidence from recent research suggests that these systems are inefficient and may contribute to physician burnout.

As a result, organizations like SHM are looking for ways that these systems can be improved.

“The growth of health IT has led to availability of large amounts of data and opportunities for applications in [artificial intelligence and machine learning,” Dr. Prasad noted. “While this has opened many avenues to help positively impact patient care and outcomes, it also poses multiple challenges like validation, customization, and governance. Hospitalists can partner with other health professions and IT leaders to work toward the common goal of improving the health of the population while also providing a positive experience to the end user.”

Another problem with current EMRs is their lack of flexibility. These systems are often not compatible with mobile devices and certain types of hardware and may be difficult or impossible to customize. They also frequently require unnecessary information during the note-taking process that results in cluttered and difficult-to-scan documentation. Improving EMR flexibility – and inviting clinicians to consult during the design process – could solve many of these problems.

New technological developments may also soon help developers improve their EMRs. In the future, as technology like natural language processing becomes more advanced and more commonly used, they may be able to make EMRs even more efficient and user friendly.

One of the most significant shifts in hospital practice over recent decades has been the widespread adoption of electronic medical records as a replacement for conventional paper records.

While EMRs show a lot of promise – having the potential to centralize and simplify clinician notes, make information more accessible and reduce paper waste – there is strong evidence that they are not working as well as they could.

Some research suggests that these systems may decrease the working efficiency of clinicians. Now, major health care institutions are looking to understand why these systems are not working — as well as how they may be improved.

A recent white paper from the Society of Hospital Medicine’s Healthcare Information Technology Special Interest Group – titled “More Caring, Less Clicking” – reviews the current shortcomings of EMRs from a hospitalist perspective and provides recommendations for how these systems can be made more workable and efficient.

The current state of EMRs

“Numerous previous papers – including SHM’s 2017 white paper ‘Hospitalist Perspectives on Electronic Medical Records’ – have linked EMRs to decreased provider satisfaction and increased burnout related to multiple issues, including an increase in ‘screen time’ as opposed to patient ‘face-to-face’ time, and limitations in usability and interoperability,” said Rupesh Prasad, MD, SFHM, medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. “Studies have shown that most of a provider’s time spent is in areas like clinical documentation, entry of orders, and accessing patient information.”

The 2017 SHM white paper referenced by Dr. Prasad reported that 74% of hospitalists surveyed were dissatisfied with their EMR. A full one-quarter of surveyed physicians went so far as saying they would prefer switching to paper record keeping.

Other research has also found a possible link between EMRs and physician burnout and dissatisfaction. It is also not uncommon for hospitalists to spend up to 25% of their time at work using their EMR – time that should, ideally, be spent with patients.

The 2017 paper also showed that clinician notes in the United States are four times longer, on average, than notes in other countries. There are a few reasons for this – including technology design and billing requirements encouraging longer notes. Whatever the cause, however, longer notes linked to physician burnout may be partially responsible for the large amounts of time physicians spend looking at EMRs.

While EMRs may hold significant potential for hospitalists, as they are designed currently, they are simply not delivering the value many expected. The new white paper from the Healthcare Information Technology Special Interest Group outlines practical changes that could be made to EMRs to improve their use in hospitals.

The paper breaks down current issues with EMRs into five broad categories – documentation, clinical decision support, order entry, communication, and data review – to discuss how EMRs are currently failing in these areas as well as how they might be improved.

Improving EMR documentation

One of the most significant hurdles clinicians currently face lies in how EMRs currently store and display documentation. Combined with physician note-taking habits, this makes these systems much less usable than they could be. Longer notes, when displayed in current EMR UIs, mostly lead to clutter, making them harder to navigate and difficult to scan quickly for important information.

The authors identify a few different ways that future EMRs may be able to help with this problem.

EMR documentation tools will likely need to be redesigned to optimize documentation entry, standardize note formatting, and improve readability. Many electronic notes contain vestigial formatting and data left over from the design of paper notes. As a result, many of these electronic notes include information that is stored elsewhere and does not need to be explicitly included in every note. Cutting down on repetitive information storage will make important information more visible and help make patient notes easier to scan.

The paper also recommends a few other features that would make documentation more readable – like allowing clinicians to write documentation in SOAP format (subjective, objective, assessment, and plan), to facilitate critical thinking during the note-taking process, and having the EMR display that documentation in APSO format (assessment, plan, subjective, objective).

Doctors have long called for APSO or another note-taking format to replace SOAP in EMRs. Designing EMRs to rearrange SOAP notes to APSO could be a compromise that improves note readability while not requiring that clinicians learn new note-taking strategies.

The paper’s authors also recommended more extensive clinician training on writing notes. While clinicians are often taught how to write certain notes – like progress notes, histories, and physical and discharge summaries – more specific guidance is not always provided. Better training provided by institutions could help improve the quality and readability of clinician notes.

These changes, however, may not be as beneficial as possible without better institutional support for clinicians. Implementing some of the biggest changes recommended by the SHM will require some level of standardization across platforms and institution commitment to training clinicians on best use practices for EMRs. Improved responsiveness to clinician needs will require a coordinated effort with backing from both administrative and governance groups.

Expanding EMR usability

“Our white paper presents evidence-based recommendations that can be implemented at the ground level in collaboration with other stakeholders, including IT, informatics, and administration, to help improve on the current state,” Dr. Prasad said.

“We believe that hospitalists as key stakeholders in health care, have both the responsibility and are uniquely positioned to directly impact EMR functionality,” he noted. “For example, hospitalists can participate in designing appropriate, actionable alerts that would help with patient safety while also improving provider efficiency. Simple steps like limiting hard stops in order entry to would help speed up the process, and free up time for direct patient care. Availability of tools like secure text messaging would help with effective patient care team communication to improve safety and care delivery.”

EMRs often lack features like voice control and speech-to-text transcription, along with other basic accessibility features like compatibility with screen readers. Implementing these features could improve the efficiency of clinicians’ note-taking while also providing wider software usability.

EMRs are not typically designed to work with mobile devices, meaning clinicians cannot enter notes or order medications until they’ve returned to their desk or workstation.

This lack of functionality creates issues in several ways. When clinicians are unable to enter notes on the move, they will need to either keep mental notes or quickly jot down paper notes. This can effectively double the amount of note-taking that clinicians must do or introduce greater room for error. In cases where progress notes are taken throughout the day, this also means the EMR’s documentation timeline may not be accurate or usable.

Requiring clinicians to return to workstations before entering order information can also increase the risk of medication errors, which remains high despite hopes that EMRs could reduce error rates.

Adding support for cross-device and mobile EMR use could help improve the efficiency of note-taking and help cut down on error. Implementing mobile access could have a few different benefits for clinicians – like improving note-taking efficiency in hospitals, where doctors often see patients far away from their workstations.

EMRs also often lack support for certain hardware, like mobile stations and widescreen monitors, which can improve a clinician’s ability to document in real-time and are a better fit in certain work flows.

The SHM paper also recommends a few other tweaks to usability – like reducing the amount of password entry and reentry – that could make these systems easier to use and more efficient.

New features – like the use of natural language processing technology to analyze and organize information contained in clinicians’ notes – could provide further benefits and take full advantage of the advanced technologies that EMRs can integrate.

Dr. Prasad noted, however, that some of these upgrades – especially EMR compatibility with mobile devices – will require some institutional support. Bring-your-own-device policies or system-provided mobile devices will be necessary if institutions want their clinicians to be able to take advantage of mobile EMR access.

These policies will also likely require some kind of mobile device management solution to manage the security of sensitive patient data as it is accessed from personal devices. This may increase the level of necessary institutional buy-in for this support to work.

Designing EMRs with clinician needs in mind

Dr. Prasad said he and his coauthors recommend that EMR developers base more of their design on the needs of clinicians.

Currently, EMR interfaces can make important data unavailable, depending on what a clinician is trying to do. As a result, clinicians often need to rely on mental recall of important information as they navigate EMR systems.

These interfaces also typically do not support any level of user customization or process-specific interfaces, meaning every clinician is working with the same interface regardless of the tasks they need to perform or the information they need access to. Allowing for customization or implementing new process- or disease-specific interfaces could help avoid some of the problems caused by one-size-fits-all interfaces, which are not necessarily compatible with every clinician work flow.

EMR interfaces should also be designed, wherever possible, with familiar or standardized formats and the use of color coding and other techniques that can make interfaces easier to navigate quickly. Right now, many EMR systems utilize inconsistent layout design that can be cluttered with irrelevant information, slowing down interface navigation and sometimes requiring backtracking from clinicians.

Ideally, this will improve the speed of information gathering and data review, reducing the amount of time clinicians need to spend working with their EMR.

The white paper also recommends that EMR designers improve alert systems so that they are more actionable and interrupt clinicians less often – and that, when they do, they ensure that clinicians can respond to them. Designers should also reduce hard-stops or in-line alerts that halt clinicians’ work flows and require immediate responses where possible.

Increased EMR support for clinical decision support systems is one of the biggest health care trends expected to be seen throughout this decade. However, many clinicians are disappointed with the lack of flexibility and optimization of the current alerts that CDS provides. Updating and improving these knowledge-based systems will likely become essential for delivering better alerts and improving decision-making and efficiency.

Overall, EMR design should be informed by the needs of the people these products are designed to support, Dr. Prasad said. The people that work with EMRs – especially frontline staff like providers, nurses, and pharmacists that regularly interact with EMRs to provide care – should be involved early on in the EMR design process. Right now, their needs are not reflected in current EMR design. EMR companies, by working with these hospital staff members, could help improve ease of use and, ideally, prevent some of the errors associated with the current implementation of these systems.

“System designers should be able to avoid some of the most common problems of EMRs – and predict potential problems – by consistently soliciting and integrating clinician feedback during the design process and over the lifespan of a product,” Dr. Prasad said.

How EMRs can be improved

Over the past few years, EMRs have become quickly adopted by health care professionals and institutions. However, despite hopes that EMRs could significantly improve record keeping and note-taking, these systems continue to pose serious challenges for the clinicians who use them. Evidence from recent research suggests that these systems are inefficient and may contribute to physician burnout.

As a result, organizations like SHM are looking for ways that these systems can be improved.

“The growth of health IT has led to availability of large amounts of data and opportunities for applications in [artificial intelligence and machine learning,” Dr. Prasad noted. “While this has opened many avenues to help positively impact patient care and outcomes, it also poses multiple challenges like validation, customization, and governance. Hospitalists can partner with other health professions and IT leaders to work toward the common goal of improving the health of the population while also providing a positive experience to the end user.”

Another problem with current EMRs is their lack of flexibility. These systems are often not compatible with mobile devices and certain types of hardware and may be difficult or impossible to customize. They also frequently require unnecessary information during the note-taking process that results in cluttered and difficult-to-scan documentation. Improving EMR flexibility – and inviting clinicians to consult during the design process – could solve many of these problems.

New technological developments may also soon help developers improve their EMRs. In the future, as technology like natural language processing becomes more advanced and more commonly used, they may be able to make EMRs even more efficient and user friendly.

A methodical, constructive, goal-oriented rapid repetition of emergency response simulations has emerged as a dominant strategy for pediatric readiness in the hospital setting, according to a detailed description of one such program at the virtual Pediatric Hospital Medicine.

Rather than a single run-through followed by a lengthy debriefing, which has been a traditional approach, short simulations done rapidly and repeatedly until skills are mastered improve skill development, according to Jeanmarie Schied, MD, of the department of pediatrics, University of Chicago Medicine.

A methodical, constructive, goal-oriented rapid repetition of emergency response simulations has emerged as a dominant strategy for pediatric readiness in the hospital setting, according to a detailed description of one such program at the virtual Pediatric Hospital Medicine.

Rather than a single run-through followed by a lengthy debriefing, which has been a traditional approach, short simulations done rapidly and repeatedly until skills are mastered improve skill development, according to Jeanmarie Schied, MD, of the department of pediatrics, University of Chicago Medicine.

A methodical, constructive, goal-oriented rapid repetition of emergency response simulations has emerged as a dominant strategy for pediatric readiness in the hospital setting, according to a detailed description of one such program at the virtual Pediatric Hospital Medicine.

Rather than a single run-through followed by a lengthy debriefing, which has been a traditional approach, short simulations done rapidly and repeatedly until skills are mastered improve skill development, according to Jeanmarie Schied, MD, of the department of pediatrics, University of Chicago Medicine.

On behalf of SHM’s Practice Analysis Committee, I am excited to announce the scheduled September 2020 release of the 2020 State of Hospital Medicine Report (SoHM)!

For reasons all too familiar, this year’s SoHM survey process was unlike any in SHM’s history. We were still collecting survey responses from a few stragglers in early March when the entire world shut down almost overnight to flatten the curve of a deadly pandemic. Hospital medicine group (HMG) leaders were suddenly either up to their eyeballs trying to figure out how to safely care for huge influxes of COVID-19 patients that overwhelmed established systems of care or were trying to figure out how to staff in a low-volume environment with few COVID patients, a relative trickle of ED admissions, and virtually no surgical care. And everywhere, hospitals and their HMGs were quickly stressed in ways that would have been unimaginable just a couple of months earlier – financially, operationally, epidemiologically, and culturally.

SHM offices closed, with all staff working from home. And the talented people who would normally have been working diligently on the survey data were suddenly redirected to focus on COVID-related issues, including tracking government announcements that were changing daily and providing needed resources to SHM members. By the time they could raise their heads and begin thinking about survey data, we were months behind schedule.

I need to give a huge shout-out to our survey manager extraordinaire Josh Lapps, SHM’s Director of Policy and Practice Management, and his survey support team including Luke Heisinger and Kim Schonberger. Once they were able to turn their focus back to the SoHM, they worked like demons to catch up. And in addition to the work of preparing the SoHM for publication, they helped issue and analyze a follow-up survey to investigate how HMGs adjusted their staffing and operations in response to COVID! As I write this, we appear to be back on schedule for a September SoHM release date, with the COVID supplemental survey report to follow soon after. Thanks also to PAC committee members who, despite their own stresses, rose to the challenge of participating in calls and planning the supplemental survey.

Despite the pandemic, HMGs found survey participation valuable. When all was said and done, we had a respectable number of respondent groups: 502 this year vs. 569 in 2018. Although the number of respondent groups is down, the average group size has increased, so that an all-time high of 10,122 employed/contracted full-time equivalent (FTE) hospitalists (plus 484 locum tenens FTEs) are represented in the data set. The respondents continue to be very diverse, representing all practice models and every state – and even a couple of other countries. One notable change is a significant increase in pediatric HM group participation, thanks to a recruitment charge led by PAC member Sandra Gage, associate division chief of hospital medicine at Phoenix Children’s Hospital, and supported by the inclusion of several new pediatric HM-specific questions to better capture unique attributes of these hospital medicine practices.

We had more multisite respondents than ever, and the multisite respondents overwhelmingly used the new “retake” feature in the online version of the survey. I’m happy to report that we received consistent positive feedback about our new electronic survey platform, and thanks to its capabilities data analysis has been significantly automated, enhancing both efficiency and data reliability.

The survey content is more wide ranging than ever. In addition to the usual topics such as scope of services, staffing and scheduling, compensation models, evaluation and management code distribution, and HM group finances, the 2020 report will include the afore-referenced information about HM groups serving children, expanded information on nurse practitioner (NPs)/physician assistant (PA) roles, and data on diversity in HM physician leadership. The follow-up COVID survey will be published separately as a supplement, available only to purchasers of the SoHM report.

Multiple options for SoHM report purchase. All survey participants will receive access to the online version of the survey. Others may purchase the hard copy report, online access, or both. The report has a colorful, easy-to-read layout, and many of the tables have been streamlined to make them easier to read. I encourage you to sign up to preorder your copy of the SoHM Report today at www.hospitalmedicine.org/sohm; you’ll almost certainly discover a treasure trove of worthwhile information.

Use the report to assess how your practice compares to other practices, but always keep in mind that surveys don’t tell you what should be; they only tell you what currently is the case – or at least, what was during the survey period. New best practices not yet reflected in survey data are emerging all the time, and that is probably more true today in the new world affected by this pandemic than ever before. And while the ways others do things won’t always be right for your group’s unique situation and needs, it always helps to know how you compare with others. Whether you are partners or employees, you and your colleagues “own” the success of your hospital medicine practice and, armed with the best available data, are the best judges of what is right for you.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey.

On behalf of SHM’s Practice Analysis Committee, I am excited to announce the scheduled September 2020 release of the 2020 State of Hospital Medicine Report (SoHM)!

For reasons all too familiar, this year’s SoHM survey process was unlike any in SHM’s history. We were still collecting survey responses from a few stragglers in early March when the entire world shut down almost overnight to flatten the curve of a deadly pandemic. Hospital medicine group (HMG) leaders were suddenly either up to their eyeballs trying to figure out how to safely care for huge influxes of COVID-19 patients that overwhelmed established systems of care or were trying to figure out how to staff in a low-volume environment with few COVID patients, a relative trickle of ED admissions, and virtually no surgical care. And everywhere, hospitals and their HMGs were quickly stressed in ways that would have been unimaginable just a couple of months earlier – financially, operationally, epidemiologically, and culturally.

SHM offices closed, with all staff working from home. And the talented people who would normally have been working diligently on the survey data were suddenly redirected to focus on COVID-related issues, including tracking government announcements that were changing daily and providing needed resources to SHM members. By the time they could raise their heads and begin thinking about survey data, we were months behind schedule.

I need to give a huge shout-out to our survey manager extraordinaire Josh Lapps, SHM’s Director of Policy and Practice Management, and his survey support team including Luke Heisinger and Kim Schonberger. Once they were able to turn their focus back to the SoHM, they worked like demons to catch up. And in addition to the work of preparing the SoHM for publication, they helped issue and analyze a follow-up survey to investigate how HMGs adjusted their staffing and operations in response to COVID! As I write this, we appear to be back on schedule for a September SoHM release date, with the COVID supplemental survey report to follow soon after. Thanks also to PAC committee members who, despite their own stresses, rose to the challenge of participating in calls and planning the supplemental survey.

Despite the pandemic, HMGs found survey participation valuable. When all was said and done, we had a respectable number of respondent groups: 502 this year vs. 569 in 2018. Although the number of respondent groups is down, the average group size has increased, so that an all-time high of 10,122 employed/contracted full-time equivalent (FTE) hospitalists (plus 484 locum tenens FTEs) are represented in the data set. The respondents continue to be very diverse, representing all practice models and every state – and even a couple of other countries. One notable change is a significant increase in pediatric HM group participation, thanks to a recruitment charge led by PAC member Sandra Gage, associate division chief of hospital medicine at Phoenix Children’s Hospital, and supported by the inclusion of several new pediatric HM-specific questions to better capture unique attributes of these hospital medicine practices.

We had more multisite respondents than ever, and the multisite respondents overwhelmingly used the new “retake” feature in the online version of the survey. I’m happy to report that we received consistent positive feedback about our new electronic survey platform, and thanks to its capabilities data analysis has been significantly automated, enhancing both efficiency and data reliability.

The survey content is more wide ranging than ever. In addition to the usual topics such as scope of services, staffing and scheduling, compensation models, evaluation and management code distribution, and HM group finances, the 2020 report will include the afore-referenced information about HM groups serving children, expanded information on nurse practitioner (NPs)/physician assistant (PA) roles, and data on diversity in HM physician leadership. The follow-up COVID survey will be published separately as a supplement, available only to purchasers of the SoHM report.

Multiple options for SoHM report purchase. All survey participants will receive access to the online version of the survey. Others may purchase the hard copy report, online access, or both. The report has a colorful, easy-to-read layout, and many of the tables have been streamlined to make them easier to read. I encourage you to sign up to preorder your copy of the SoHM Report today at www.hospitalmedicine.org/sohm; you’ll almost certainly discover a treasure trove of worthwhile information.

Use the report to assess how your practice compares to other practices, but always keep in mind that surveys don’t tell you what should be; they only tell you what currently is the case – or at least, what was during the survey period. New best practices not yet reflected in survey data are emerging all the time, and that is probably more true today in the new world affected by this pandemic than ever before. And while the ways others do things won’t always be right for your group’s unique situation and needs, it always helps to know how you compare with others. Whether you are partners or employees, you and your colleagues “own” the success of your hospital medicine practice and, armed with the best available data, are the best judges of what is right for you.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey.

On behalf of SHM’s Practice Analysis Committee, I am excited to announce the scheduled September 2020 release of the 2020 State of Hospital Medicine Report (SoHM)!

For reasons all too familiar, this year’s SoHM survey process was unlike any in SHM’s history. We were still collecting survey responses from a few stragglers in early March when the entire world shut down almost overnight to flatten the curve of a deadly pandemic. Hospital medicine group (HMG) leaders were suddenly either up to their eyeballs trying to figure out how to safely care for huge influxes of COVID-19 patients that overwhelmed established systems of care or were trying to figure out how to staff in a low-volume environment with few COVID patients, a relative trickle of ED admissions, and virtually no surgical care. And everywhere, hospitals and their HMGs were quickly stressed in ways that would have been unimaginable just a couple of months earlier – financially, operationally, epidemiologically, and culturally.

SHM offices closed, with all staff working from home. And the talented people who would normally have been working diligently on the survey data were suddenly redirected to focus on COVID-related issues, including tracking government announcements that were changing daily and providing needed resources to SHM members. By the time they could raise their heads and begin thinking about survey data, we were months behind schedule.

I need to give a huge shout-out to our survey manager extraordinaire Josh Lapps, SHM’s Director of Policy and Practice Management, and his survey support team including Luke Heisinger and Kim Schonberger. Once they were able to turn their focus back to the SoHM, they worked like demons to catch up. And in addition to the work of preparing the SoHM for publication, they helped issue and analyze a follow-up survey to investigate how HMGs adjusted their staffing and operations in response to COVID! As I write this, we appear to be back on schedule for a September SoHM release date, with the COVID supplemental survey report to follow soon after. Thanks also to PAC committee members who, despite their own stresses, rose to the challenge of participating in calls and planning the supplemental survey.

Despite the pandemic, HMGs found survey participation valuable. When all was said and done, we had a respectable number of respondent groups: 502 this year vs. 569 in 2018. Although the number of respondent groups is down, the average group size has increased, so that an all-time high of 10,122 employed/contracted full-time equivalent (FTE) hospitalists (plus 484 locum tenens FTEs) are represented in the data set. The respondents continue to be very diverse, representing all practice models and every state – and even a couple of other countries. One notable change is a significant increase in pediatric HM group participation, thanks to a recruitment charge led by PAC member Sandra Gage, associate division chief of hospital medicine at Phoenix Children’s Hospital, and supported by the inclusion of several new pediatric HM-specific questions to better capture unique attributes of these hospital medicine practices.

We had more multisite respondents than ever, and the multisite respondents overwhelmingly used the new “retake” feature in the online version of the survey. I’m happy to report that we received consistent positive feedback about our new electronic survey platform, and thanks to its capabilities data analysis has been significantly automated, enhancing both efficiency and data reliability.

The survey content is more wide ranging than ever. In addition to the usual topics such as scope of services, staffing and scheduling, compensation models, evaluation and management code distribution, and HM group finances, the 2020 report will include the afore-referenced information about HM groups serving children, expanded information on nurse practitioner (NPs)/physician assistant (PA) roles, and data on diversity in HM physician leadership. The follow-up COVID survey will be published separately as a supplement, available only to purchasers of the SoHM report.

Multiple options for SoHM report purchase. All survey participants will receive access to the online version of the survey. Others may purchase the hard copy report, online access, or both. The report has a colorful, easy-to-read layout, and many of the tables have been streamlined to make them easier to read. I encourage you to sign up to preorder your copy of the SoHM Report today at www.hospitalmedicine.org/sohm; you’ll almost certainly discover a treasure trove of worthwhile information.

Use the report to assess how your practice compares to other practices, but always keep in mind that surveys don’t tell you what should be; they only tell you what currently is the case – or at least, what was during the survey period. New best practices not yet reflected in survey data are emerging all the time, and that is probably more true today in the new world affected by this pandemic than ever before. And while the ways others do things won’t always be right for your group’s unique situation and needs, it always helps to know how you compare with others. Whether you are partners or employees, you and your colleagues “own” the success of your hospital medicine practice and, armed with the best available data, are the best judges of what is right for you.
 

Ms. Flores is a partner at Nelson Flores Hospital Medicine Consultants in La Quinta, Calif. She serves on SHM’s Practice Analysis and Annual Conference Committees and helps to coordinate SHM’s biannual State of Hospital Medicine survey.

The rapid decline in pediatric hospital visits that came quickly after COVID-19 has emerged as a major public health threat, creating the need for adaptations among those offering hospital-based care, according to an objective look at patient numbers that was presented at the virtual Pediatric Hospital Medicine.

“Pre-COVID, operating margins had already taken a significant decline – and there are lots of different reasons for why this was happening – but a lot of hospitals in the United States were going from seeing about a 5% operating margin to closer to 2% to 3%,” said Magna Dias, MD, medical director, pediatric inpatient services, at Yale New Haven Children’s Hospital, Bridgeport, Conn.

This nearly 50% decline “was already putting pressure on us in the community hospital setting where pediatrics is not necessarily generating a ton of revenue to justify our programs, but post COVID, our operating revenue – and this is a report from May – was down 282%,” Dr. Dias reported.

Dr. Dias said that hundreds of hospitals have furloughed workers in the United States since the pandemic began. Although the job losses are not confined to pediatric care, statistics show that pediatrics is one of the hardest hit specialties.

“Looking specifically at ED [emergency department] visits under age 14, one study showed a 71% to 72% decrease post COVID,” Dr. Dias said. This included a 97% reduction in ED visits for flu and more than an 80% reduction in visits for asthma, otitis media, and nausea or vomiting.

It is not clear when children will return to the hospital in pre-COVID-19 numbers, but it might not be soon if the a second wave of infections follows the first, according to Dr. Dias. She suggested that pediatric hospitalists should be thinking about how to expand their services.

“One thing we are really good at in terms of working in the community hospital is diversification. We are used to working in more than one area and being flexible,” Dr. Dias said. Quoting Charles Darwin, who concluded that adaption to change predicts species survival, Dr. Dias advised pediatric hospitalists to look for new opportunities.

Taking on a broader range of responsibilities will not be a significant leap for many pediatric hospitalists. In a survey conducted several years ago by the American Academy of Pediatrics (AAP), hospital staff pediatricians were associated with activities ranging from work in the neonatal intensive care unit to primary ED coverage, according to Dr. Dias. Now with declining patient volumes on pediatric floors, she foresees an even greater expansion, including the care of young adults.

One organization formed in response to the COVID-19 pandemic, called the Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been taking a lead in guiding the delivery of adult care in a pediatric environment. As a cochair of a community hospital special interest group within POPCoRN, Dr. Dias said she has participated in these discussions.

“At some centers, they have gone from age 18 to 21, some have gone up to age 25, some have gone up to 30 years,” she said.

Many centers are working to leverage telemedicine to reach pediatric patients no longer coming to the hospital, according to Dr. Dias.

“There are a lot of people being very creative in telemedicine,” she said. While it is considered as one way “to keep children at your institution,” Dr. Dias said others are considering how telemedicine might provide new opportunities. For one example, telemedicine might be an opportunity to deliver care in rural hospitals without pediatric services.

In an AAP survey of pediatric hospitalists conducted several years ago, justifying services was listed as the second most important concern right after access to subspecialty support. Due to COVID-19, Dr. Dias expects the order of these concerns to flip. Indeed, she predicted that many pediatric hospitalists are going to need to reassess their programs.

“We have started looking at what are our opportunities for building back revenue as well as how to recession-proof our practices should there be another surge and another decrease in pediatric volume,” Dr. Dias said.

The changes in pediatric care are not confined to the hospital setting. According to Amy H. Porter, MD, assistant professor of pediatrics at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., COVID-19 has “changed the way pediatric medicine is being practiced.”

Although she works in outpatient pediatric care, she said that routine care “is way down” in this setting as well. Like Dr. Dias, she has witnessed a major increase in the use of telemedicine to reach pediatric patients, but she is very concerned about the large proportion of children who are missing routine care, including vaccinations.

“We were already seeing outbreaks of whooping cough and measles pre COVID, so we are quite worried that we will see more,” Dr. Porter said.

A reduction in demand for care does not have the same immediate effect on revenue at a large health maintenance organization like Kaiser Permanente, but growing unemployment in the general population will mean fewer HMO members. In turn, this could have an impact on the entire system.

“When membership goes down, then it will have implications for how we can provide services,” Dr. Porter said.

In the meantime, social workers at Kaiser Permanente “are tirelessly working” to help parents losing benefits to obtain medicines for sick children with chronic diseases, according to Dr. Porter. She echoed the comments of Dr. Dias in predicting major changes in pediatric care if the COVID-19 pandemic and its economic consequences persist.

The conference was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The rapid decline in pediatric hospital visits that came quickly after COVID-19 has emerged as a major public health threat, creating the need for adaptations among those offering hospital-based care, according to an objective look at patient numbers that was presented at the virtual Pediatric Hospital Medicine.

“Pre-COVID, operating margins had already taken a significant decline – and there are lots of different reasons for why this was happening – but a lot of hospitals in the United States were going from seeing about a 5% operating margin to closer to 2% to 3%,” said Magna Dias, MD, medical director, pediatric inpatient services, at Yale New Haven Children’s Hospital, Bridgeport, Conn.

This nearly 50% decline “was already putting pressure on us in the community hospital setting where pediatrics is not necessarily generating a ton of revenue to justify our programs, but post COVID, our operating revenue – and this is a report from May – was down 282%,” Dr. Dias reported.

Dr. Dias said that hundreds of hospitals have furloughed workers in the United States since the pandemic began. Although the job losses are not confined to pediatric care, statistics show that pediatrics is one of the hardest hit specialties.

“Looking specifically at ED [emergency department] visits under age 14, one study showed a 71% to 72% decrease post COVID,” Dr. Dias said. This included a 97% reduction in ED visits for flu and more than an 80% reduction in visits for asthma, otitis media, and nausea or vomiting.

It is not clear when children will return to the hospital in pre-COVID-19 numbers, but it might not be soon if the a second wave of infections follows the first, according to Dr. Dias. She suggested that pediatric hospitalists should be thinking about how to expand their services.

“One thing we are really good at in terms of working in the community hospital is diversification. We are used to working in more than one area and being flexible,” Dr. Dias said. Quoting Charles Darwin, who concluded that adaption to change predicts species survival, Dr. Dias advised pediatric hospitalists to look for new opportunities.

Taking on a broader range of responsibilities will not be a significant leap for many pediatric hospitalists. In a survey conducted several years ago by the American Academy of Pediatrics (AAP), hospital staff pediatricians were associated with activities ranging from work in the neonatal intensive care unit to primary ED coverage, according to Dr. Dias. Now with declining patient volumes on pediatric floors, she foresees an even greater expansion, including the care of young adults.

One organization formed in response to the COVID-19 pandemic, called the Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been taking a lead in guiding the delivery of adult care in a pediatric environment. As a cochair of a community hospital special interest group within POPCoRN, Dr. Dias said she has participated in these discussions.

“At some centers, they have gone from age 18 to 21, some have gone up to age 25, some have gone up to 30 years,” she said.

Many centers are working to leverage telemedicine to reach pediatric patients no longer coming to the hospital, according to Dr. Dias.

“There are a lot of people being very creative in telemedicine,” she said. While it is considered as one way “to keep children at your institution,” Dr. Dias said others are considering how telemedicine might provide new opportunities. For one example, telemedicine might be an opportunity to deliver care in rural hospitals without pediatric services.

In an AAP survey of pediatric hospitalists conducted several years ago, justifying services was listed as the second most important concern right after access to subspecialty support. Due to COVID-19, Dr. Dias expects the order of these concerns to flip. Indeed, she predicted that many pediatric hospitalists are going to need to reassess their programs.

“We have started looking at what are our opportunities for building back revenue as well as how to recession-proof our practices should there be another surge and another decrease in pediatric volume,” Dr. Dias said.

The changes in pediatric care are not confined to the hospital setting. According to Amy H. Porter, MD, assistant professor of pediatrics at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., COVID-19 has “changed the way pediatric medicine is being practiced.”

Although she works in outpatient pediatric care, she said that routine care “is way down” in this setting as well. Like Dr. Dias, she has witnessed a major increase in the use of telemedicine to reach pediatric patients, but she is very concerned about the large proportion of children who are missing routine care, including vaccinations.

“We were already seeing outbreaks of whooping cough and measles pre COVID, so we are quite worried that we will see more,” Dr. Porter said.

A reduction in demand for care does not have the same immediate effect on revenue at a large health maintenance organization like Kaiser Permanente, but growing unemployment in the general population will mean fewer HMO members. In turn, this could have an impact on the entire system.

“When membership goes down, then it will have implications for how we can provide services,” Dr. Porter said.

In the meantime, social workers at Kaiser Permanente “are tirelessly working” to help parents losing benefits to obtain medicines for sick children with chronic diseases, according to Dr. Porter. She echoed the comments of Dr. Dias in predicting major changes in pediatric care if the COVID-19 pandemic and its economic consequences persist.

The conference was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

The rapid decline in pediatric hospital visits that came quickly after COVID-19 has emerged as a major public health threat, creating the need for adaptations among those offering hospital-based care, according to an objective look at patient numbers that was presented at the virtual Pediatric Hospital Medicine.

“Pre-COVID, operating margins had already taken a significant decline – and there are lots of different reasons for why this was happening – but a lot of hospitals in the United States were going from seeing about a 5% operating margin to closer to 2% to 3%,” said Magna Dias, MD, medical director, pediatric inpatient services, at Yale New Haven Children’s Hospital, Bridgeport, Conn.

This nearly 50% decline “was already putting pressure on us in the community hospital setting where pediatrics is not necessarily generating a ton of revenue to justify our programs, but post COVID, our operating revenue – and this is a report from May – was down 282%,” Dr. Dias reported.

Dr. Dias said that hundreds of hospitals have furloughed workers in the United States since the pandemic began. Although the job losses are not confined to pediatric care, statistics show that pediatrics is one of the hardest hit specialties.

“Looking specifically at ED [emergency department] visits under age 14, one study showed a 71% to 72% decrease post COVID,” Dr. Dias said. This included a 97% reduction in ED visits for flu and more than an 80% reduction in visits for asthma, otitis media, and nausea or vomiting.

It is not clear when children will return to the hospital in pre-COVID-19 numbers, but it might not be soon if the a second wave of infections follows the first, according to Dr. Dias. She suggested that pediatric hospitalists should be thinking about how to expand their services.

“One thing we are really good at in terms of working in the community hospital is diversification. We are used to working in more than one area and being flexible,” Dr. Dias said. Quoting Charles Darwin, who concluded that adaption to change predicts species survival, Dr. Dias advised pediatric hospitalists to look for new opportunities.

Taking on a broader range of responsibilities will not be a significant leap for many pediatric hospitalists. In a survey conducted several years ago by the American Academy of Pediatrics (AAP), hospital staff pediatricians were associated with activities ranging from work in the neonatal intensive care unit to primary ED coverage, according to Dr. Dias. Now with declining patient volumes on pediatric floors, she foresees an even greater expansion, including the care of young adults.

One organization formed in response to the COVID-19 pandemic, called the Pediatric Overflow Planning Contingency Response Network (POPCoRN) has been taking a lead in guiding the delivery of adult care in a pediatric environment. As a cochair of a community hospital special interest group within POPCoRN, Dr. Dias said she has participated in these discussions.

“At some centers, they have gone from age 18 to 21, some have gone up to age 25, some have gone up to 30 years,” she said.

Many centers are working to leverage telemedicine to reach pediatric patients no longer coming to the hospital, according to Dr. Dias.

“There are a lot of people being very creative in telemedicine,” she said. While it is considered as one way “to keep children at your institution,” Dr. Dias said others are considering how telemedicine might provide new opportunities. For one example, telemedicine might be an opportunity to deliver care in rural hospitals without pediatric services.

In an AAP survey of pediatric hospitalists conducted several years ago, justifying services was listed as the second most important concern right after access to subspecialty support. Due to COVID-19, Dr. Dias expects the order of these concerns to flip. Indeed, she predicted that many pediatric hospitalists are going to need to reassess their programs.

“We have started looking at what are our opportunities for building back revenue as well as how to recession-proof our practices should there be another surge and another decrease in pediatric volume,” Dr. Dias said.

The changes in pediatric care are not confined to the hospital setting. According to Amy H. Porter, MD, assistant professor of pediatrics at the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, Calif., COVID-19 has “changed the way pediatric medicine is being practiced.”

Although she works in outpatient pediatric care, she said that routine care “is way down” in this setting as well. Like Dr. Dias, she has witnessed a major increase in the use of telemedicine to reach pediatric patients, but she is very concerned about the large proportion of children who are missing routine care, including vaccinations.

“We were already seeing outbreaks of whooping cough and measles pre COVID, so we are quite worried that we will see more,” Dr. Porter said.

A reduction in demand for care does not have the same immediate effect on revenue at a large health maintenance organization like Kaiser Permanente, but growing unemployment in the general population will mean fewer HMO members. In turn, this could have an impact on the entire system.

“When membership goes down, then it will have implications for how we can provide services,” Dr. Porter said.

In the meantime, social workers at Kaiser Permanente “are tirelessly working” to help parents losing benefits to obtain medicines for sick children with chronic diseases, according to Dr. Porter. She echoed the comments of Dr. Dias in predicting major changes in pediatric care if the COVID-19 pandemic and its economic consequences persist.

The conference was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

For the fifth consecutive year, the Mayo Clinic in Rochester, Minnesota, claimed the number one spot in the annual honor roll of best hospitals, published today by US News & World Report.

This year’s rankings include special recognition of the “herculean efforts” by the nation’s healthcare professionals in fighting COVID-19, often at great personal risk.

“The US News Hospital Heroes series is a cornerstone of this year’s rankings package, profiling more than 65 health care heroes from across the country, along with commentary from top executives at hospitals who faced the pandemic head on,” a news release from the magazine explains.

“The pandemic has altered, perhaps permanently, how patients get care and from whom they get it. Amid the disruption, we are steadfastly committed to providing the public with authoritative data for comparing hospital quality,” Ben Harder, managing editor and chief of health analysis at US News, said in the release.

“No hospital’s clinical team came through this unprecedented health crisis unscathed. Our Hospital Heroes series is a tribute to recognizing individuals at urban and rural hospitals in communities across the country who have gone above and beyond during this unparalleled time in history,” said Harder.

Mayo Clinic Still Number One

Following Mayo Clinic, Cleveland Clinic in Ohio takes the number two spot this year (up from number four last year) in the magazine’s annual honor roll, which highlights hospitals that deliver “exceptional treatment across multiple areas of care.”

Johns Hopkins Hospital in Baltimore, Maryland, holds the number three spot, while New York-Presbyterian Hospital–Columbia and Cornell in New York City and UCLA Medical Center, Los Angeles, tie for the number four spot.

Massachusetts General Hospital in Boston, which held the number two spot last year, has fallen to number six. Rounding out the top 10, in order, are Cedars-Sinai Medical Center, Los Angeles; UCSF Medical Center, San Francisco; NYU Langone Hospitals, New York City; Northwestern Memorial Hospital, Chicago, Illinois.

2020–2021 Best Hospitals Honor Roll

1. Mayo Clinic, Rochester, Minnesota

2. Cleveland Clinic, Ohio

3. Johns Hopkins Hospital, Baltimore, Maryland

4. (tie) New York–Presbyterian Hospital–Columbia and Cornell, New York City

4. (tie) UCLA Medical Center, Los Angeles

6. Massachusetts General Hospital, Boston

7. Cedars-Sinai Medical Center, San Francisco

8. UCSF Medical Center, San Francisco

9. NYU Langone Hospitals, New York, New York City

10. Northwestern Memorial Hospital, Chicago

11. University of Michigan Hospitals–Michigan Medicine, Ann Arbor

12. Brigham and Women’s Hospital, Boston

13. Stanford Health Care–Stanford Hospital, Palo Alto, California

14. Mount Sinai Hospital, New York City

15. Hospitals of the University of Pennsylvania–Penn Presbyterian, Philadelphia

16. Mayo Clinic–Phoenix

17. Rush University Medical Center, Chicago

18. (tie) Barnes-Jewish Hospital, Saint Louis

18. (tie) Keck Hospital of USC, Los Angeles

20. Houston Methodist Hospital, Texas

In the 2020–2021 Best Hospitals: Specialty Rankings, University of Texas MD Anderson Cancer Center continues to hold the number one spot in cancer, the Hospital for Special Surgery is number one in orthopedics, and the Cleveland Clinic is number one in cardiology and heart surgery.

For this year’s rankings, US News developed a new cardiac rating that measures the quality of hospitals› transcatheter aortic valve replacement, which is rapidly being adopted as a minimally invasive alternative to aortic valve surgery.

Top Five for Cancer

1. University of Texas MD Anderson Cancer Center, Houston

2. Memorial Sloan Kettering Cancer Center, New York City

3. Mayo Clinic, Rochester, Minnesota

4. Johns Hopkins Hospital, Baltimore, Maryland

5. Cleveland Clinic, Ohio

 

Top Five for Cardiology and Heart Surgery

1. Cleveland Clinic, Ohio

2. Mayo Clinic, Rochester, Minnesota

3. Cedars-Sinai Medical Center, Los Angeles

4. New York–Presbyterian Hospital–Columbia and Cornell, NYC

5. Massachusetts General Hospital, Boston

 

Top Five for Orthopedics

1. Hospital for Special Surgery, New York City

2. Mayo Clinic, Rochester, Minnesota

3. Cedars-Sinai Medical Center, Los Angeles

4. NYU Langone Orthopedic Hospital, New York City

5. Rush University Medical Center, Chicago

For the 2020–2021 rankings and ratings, US News compared more than 4500 medical centers across the country in 16 specialties and 10 procedures and conditions. Of these, 563 were recognized as Best Regional Hospitals on the basis of their strong performance in multiple areas of care. The top 20 hospitals, which deliver exceptional treatment across many areas of care, were also named to the honor roll.

The magazine notes that data for the 2020–2021 Best Hospitals rankings and ratings come from a period predating the COVID-19 pandemic and were not affected by the pandemic’s impact on hospitals. The methodologies are based largely on objective measures, such as risk-adjusted survival and discharge-to-home rates, volume, and quality of nursing, among other care-related indicators.

The full report on hospital ranking is available online.
 

This article first appeared on Medscape.com.

For the fifth consecutive year, the Mayo Clinic in Rochester, Minnesota, claimed the number one spot in the annual honor roll of best hospitals, published today by US News & World Report.

This year’s rankings include special recognition of the “herculean efforts” by the nation’s healthcare professionals in fighting COVID-19, often at great personal risk.

“The US News Hospital Heroes series is a cornerstone of this year’s rankings package, profiling more than 65 health care heroes from across the country, along with commentary from top executives at hospitals who faced the pandemic head on,” a news release from the magazine explains.

“The pandemic has altered, perhaps permanently, how patients get care and from whom they get it. Amid the disruption, we are steadfastly committed to providing the public with authoritative data for comparing hospital quality,” Ben Harder, managing editor and chief of health analysis at US News, said in the release.

“No hospital’s clinical team came through this unprecedented health crisis unscathed. Our Hospital Heroes series is a tribute to recognizing individuals at urban and rural hospitals in communities across the country who have gone above and beyond during this unparalleled time in history,” said Harder.

Mayo Clinic Still Number One

Following Mayo Clinic, Cleveland Clinic in Ohio takes the number two spot this year (up from number four last year) in the magazine’s annual honor roll, which highlights hospitals that deliver “exceptional treatment across multiple areas of care.”

Johns Hopkins Hospital in Baltimore, Maryland, holds the number three spot, while New York-Presbyterian Hospital–Columbia and Cornell in New York City and UCLA Medical Center, Los Angeles, tie for the number four spot.

Massachusetts General Hospital in Boston, which held the number two spot last year, has fallen to number six. Rounding out the top 10, in order, are Cedars-Sinai Medical Center, Los Angeles; UCSF Medical Center, San Francisco; NYU Langone Hospitals, New York City; Northwestern Memorial Hospital, Chicago, Illinois.

2020–2021 Best Hospitals Honor Roll

1. Mayo Clinic, Rochester, Minnesota

2. Cleveland Clinic, Ohio

3. Johns Hopkins Hospital, Baltimore, Maryland

4. (tie) New York–Presbyterian Hospital–Columbia and Cornell, New York City

4. (tie) UCLA Medical Center, Los Angeles

6. Massachusetts General Hospital, Boston

7. Cedars-Sinai Medical Center, San Francisco

8. UCSF Medical Center, San Francisco

9. NYU Langone Hospitals, New York, New York City

10. Northwestern Memorial Hospital, Chicago

11. University of Michigan Hospitals–Michigan Medicine, Ann Arbor

12. Brigham and Women’s Hospital, Boston

13. Stanford Health Care–Stanford Hospital, Palo Alto, California

14. Mount Sinai Hospital, New York City

15. Hospitals of the University of Pennsylvania–Penn Presbyterian, Philadelphia

16. Mayo Clinic–Phoenix

17. Rush University Medical Center, Chicago

18. (tie) Barnes-Jewish Hospital, Saint Louis

18. (tie) Keck Hospital of USC, Los Angeles

20. Houston Methodist Hospital, Texas

In the 2020–2021 Best Hospitals: Specialty Rankings, University of Texas MD Anderson Cancer Center continues to hold the number one spot in cancer, the Hospital for Special Surgery is number one in orthopedics, and the Cleveland Clinic is number one in cardiology and heart surgery.

For this year’s rankings, US News developed a new cardiac rating that measures the quality of hospitals› transcatheter aortic valve replacement, which is rapidly being adopted as a minimally invasive alternative to aortic valve surgery.

Top Five for Cancer

1. University of Texas MD Anderson Cancer Center, Houston

2. Memorial Sloan Kettering Cancer Center, New York City

3. Mayo Clinic, Rochester, Minnesota

4. Johns Hopkins Hospital, Baltimore, Maryland

5. Cleveland Clinic, Ohio

 

Top Five for Cardiology and Heart Surgery

1. Cleveland Clinic, Ohio

2. Mayo Clinic, Rochester, Minnesota

3. Cedars-Sinai Medical Center, Los Angeles

4. New York–Presbyterian Hospital–Columbia and Cornell, NYC

5. Massachusetts General Hospital, Boston

 

Top Five for Orthopedics

1. Hospital for Special Surgery, New York City

2. Mayo Clinic, Rochester, Minnesota

3. Cedars-Sinai Medical Center, Los Angeles

4. NYU Langone Orthopedic Hospital, New York City

5. Rush University Medical Center, Chicago

For the 2020–2021 rankings and ratings, US News compared more than 4500 medical centers across the country in 16 specialties and 10 procedures and conditions. Of these, 563 were recognized as Best Regional Hospitals on the basis of their strong performance in multiple areas of care. The top 20 hospitals, which deliver exceptional treatment across many areas of care, were also named to the honor roll.

The magazine notes that data for the 2020–2021 Best Hospitals rankings and ratings come from a period predating the COVID-19 pandemic and were not affected by the pandemic’s impact on hospitals. The methodologies are based largely on objective measures, such as risk-adjusted survival and discharge-to-home rates, volume, and quality of nursing, among other care-related indicators.

The full report on hospital ranking is available online.
 

This article first appeared on Medscape.com.

For the fifth consecutive year, the Mayo Clinic in Rochester, Minnesota, claimed the number one spot in the annual honor roll of best hospitals, published today by US News & World Report.

This year’s rankings include special recognition of the “herculean efforts” by the nation’s healthcare professionals in fighting COVID-19, often at great personal risk.

“The US News Hospital Heroes series is a cornerstone of this year’s rankings package, profiling more than 65 health care heroes from across the country, along with commentary from top executives at hospitals who faced the pandemic head on,” a news release from the magazine explains.

“The pandemic has altered, perhaps permanently, how patients get care and from whom they get it. Amid the disruption, we are steadfastly committed to providing the public with authoritative data for comparing hospital quality,” Ben Harder, managing editor and chief of health analysis at US News, said in the release.

“No hospital’s clinical team came through this unprecedented health crisis unscathed. Our Hospital Heroes series is a tribute to recognizing individuals at urban and rural hospitals in communities across the country who have gone above and beyond during this unparalleled time in history,” said Harder.

Mayo Clinic Still Number One

Following Mayo Clinic, Cleveland Clinic in Ohio takes the number two spot this year (up from number four last year) in the magazine’s annual honor roll, which highlights hospitals that deliver “exceptional treatment across multiple areas of care.”

Johns Hopkins Hospital in Baltimore, Maryland, holds the number three spot, while New York-Presbyterian Hospital–Columbia and Cornell in New York City and UCLA Medical Center, Los Angeles, tie for the number four spot.

Massachusetts General Hospital in Boston, which held the number two spot last year, has fallen to number six. Rounding out the top 10, in order, are Cedars-Sinai Medical Center, Los Angeles; UCSF Medical Center, San Francisco; NYU Langone Hospitals, New York City; Northwestern Memorial Hospital, Chicago, Illinois.

2020–2021 Best Hospitals Honor Roll

1. Mayo Clinic, Rochester, Minnesota

2. Cleveland Clinic, Ohio

3. Johns Hopkins Hospital, Baltimore, Maryland

4. (tie) New York–Presbyterian Hospital–Columbia and Cornell, New York City

4. (tie) UCLA Medical Center, Los Angeles

6. Massachusetts General Hospital, Boston

7. Cedars-Sinai Medical Center, San Francisco

8. UCSF Medical Center, San Francisco

9. NYU Langone Hospitals, New York, New York City

10. Northwestern Memorial Hospital, Chicago

11. University of Michigan Hospitals–Michigan Medicine, Ann Arbor

12. Brigham and Women’s Hospital, Boston

13. Stanford Health Care–Stanford Hospital, Palo Alto, California

14. Mount Sinai Hospital, New York City

15. Hospitals of the University of Pennsylvania–Penn Presbyterian, Philadelphia

16. Mayo Clinic–Phoenix

17. Rush University Medical Center, Chicago

18. (tie) Barnes-Jewish Hospital, Saint Louis

18. (tie) Keck Hospital of USC, Los Angeles

20. Houston Methodist Hospital, Texas

In the 2020–2021 Best Hospitals: Specialty Rankings, University of Texas MD Anderson Cancer Center continues to hold the number one spot in cancer, the Hospital for Special Surgery is number one in orthopedics, and the Cleveland Clinic is number one in cardiology and heart surgery.

For this year’s rankings, US News developed a new cardiac rating that measures the quality of hospitals› transcatheter aortic valve replacement, which is rapidly being adopted as a minimally invasive alternative to aortic valve surgery.

Top Five for Cancer

1. University of Texas MD Anderson Cancer Center, Houston

2. Memorial Sloan Kettering Cancer Center, New York City

3. Mayo Clinic, Rochester, Minnesota

4. Johns Hopkins Hospital, Baltimore, Maryland

5. Cleveland Clinic, Ohio

 

Top Five for Cardiology and Heart Surgery

1. Cleveland Clinic, Ohio

2. Mayo Clinic, Rochester, Minnesota

3. Cedars-Sinai Medical Center, Los Angeles

4. New York–Presbyterian Hospital–Columbia and Cornell, NYC

5. Massachusetts General Hospital, Boston

 

Top Five for Orthopedics

1. Hospital for Special Surgery, New York City

2. Mayo Clinic, Rochester, Minnesota

3. Cedars-Sinai Medical Center, Los Angeles

4. NYU Langone Orthopedic Hospital, New York City

5. Rush University Medical Center, Chicago

For the 2020–2021 rankings and ratings, US News compared more than 4500 medical centers across the country in 16 specialties and 10 procedures and conditions. Of these, 563 were recognized as Best Regional Hospitals on the basis of their strong performance in multiple areas of care. The top 20 hospitals, which deliver exceptional treatment across many areas of care, were also named to the honor roll.

The magazine notes that data for the 2020–2021 Best Hospitals rankings and ratings come from a period predating the COVID-19 pandemic and were not affected by the pandemic’s impact on hospitals. The methodologies are based largely on objective measures, such as risk-adjusted survival and discharge-to-home rates, volume, and quality of nursing, among other care-related indicators.

The full report on hospital ranking is available online.
 

This article first appeared on Medscape.com.

Since the early 2000s, approximately half of medical students in the United States – and in many years, more than half – have been women, but the proportion of women occupying leadership roles in medicine remains low, according to an update provided at the virtual Pediatric Hospital Medicine.

In pediatrics, a specialty in which approximately 70% of physicians are now women, there has been progress, but still less than 30% of pediatric department chairs are female, said Vincent Chiang, MD, chief medical officer of Boston Children’s Hospital, during a presentation at the virtual meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Citing published data and a survey he personally conducted of the top children’s hospitals identified by the U.S. News and World Report, Dr. Chiang said a minority of division chiefs, chief medical officers, chief financial officers, and other leaders are female. At his institution, only 2 of 16 division chiefs are female.

“No matter how you slice it, women are underrepresented in leadership positions,” he noted.

The problem is certainly not confined to medicine. Dr. Chiang cited data showing that women and men have reached “near parity” in workforce participation in the United States even though the 20% earnings gap has changed little over time.

According to 2020 data from the World Economic Forum, the United States ranked 51 for the gender gap calculated on the basis of economic, political, educational, and health attainment. Even if this places the United States in the top third of the rankings, it is far behind Iceland and the Scandinavian countries that lead the list.

Efforts to reduce structural biases are part of the fix, but Dr. Chiang cautioned that fundamental changes might never occur if the plan is to wait for an approach based on meritocracy. He said that existing structural biases are “slanted away from women,” who are not necessarily granted the opportunities that are readily available to men.

“A meritocracy only works if the initial playing field was level. Otherwise, it just perpetuates the inequalities,” he said.

The problem is not a shortage of women with the skills to lead. In a study by Zenger/Folkman, a consulting company that works on leadership skill development, women performed better than men in 16 of 18 leadership categories, according to Dr. Chiang.

“There is certainly no shortage of capable women,” he noted.

Of the many issues, Dr. Chiang highlighted two. The first is the challenge of placing women on leadership pathways. This is likely to require proactive strategies, such as fast-track advancement programs that guide female candidates toward leadership roles.

The second is more nuanced. According to Dr. Chiang, women who want to assume a leadership role should think more actively about how and who is making decisions at their institution so they can position themselves appropriately. This is nuanced because “there is a certain amount of gamesmanship,” he said. The rise to leadership “has never been a pure meritocracy.”

Importantly, many of the key decisions in any institution involve money, according to Dr. Chiang. As a result, he advised those seeking leadership roles to join audit committees or otherwise take on responsibility for profit-and-loss management. Even in a nonprofit institution, “you need to make the numbers work,” he said, citing the common catchphrase: “No margin, no mission.”

However, Dr. Chiang acknowledged the many obstacles that prevent women from working their way into positions of leadership. For example, networking is important, but women are not necessarily attracted or invited to some of the social engagements, such as golf outings, where strong relationships are created.

In a survey of 100,000 people working at Fortune 500 companies, “82% of women say they feel excluded at work and much of that comes from that informal networking,” Dr. Chiang said. “Whereas 92% of men think they are not excluding women in their daily work.”

There is no single solution, but Dr. Chiang believes that concrete structural changes are needed. Female doctors remain grossly underrepresented in leadership roles even as they now represent more than half of the workforce for many specialties. Based on the need for proactive approaches outlined by Dr. Chiang, it appears unlikely that gender inequality will ever resolve itself.

Lisa S. Rotenstein, MD, who has written on fixing the gender imbalance in health care, including for the Harvard Business Review, said she agreed during an interview that structural changes are critical.

“In order to address current disparities, leaders should be thinking about how to remove both the formal and informal obstacles that prevent women and minorities from getting into the rooms where these decisions are being made,” said Dr. Rotenstein, who is an instructor in medicine at Brigham and Women’s Hospital, Harvard Medical School in Boston.

“This will need to involve sponsorship that gets women invited to the right committees or in positions with responsibility for profit-and-loss management,” she added.

Dr. Rotenstein spoke about improving “access to the pipeline” that leads to leadership roles. The ways in which women are excluded from opportunities is often subtle and difficult to penetrate without fundamental changes, she explained.

“Institutions need to understand the processes that lead to leadership roles and make the changes that allow women and minorities to participate,” she said. It is not enough to recognize the problem, according to Dr. Rotenstein.

Like Dr. Chiang, she noted that changes are needed in the methods that move underrepresented groups into leadership roles.

Dr. Chiang reported no potential conflicts of interest relevant to this study.

Since the early 2000s, approximately half of medical students in the United States – and in many years, more than half – have been women, but the proportion of women occupying leadership roles in medicine remains low, according to an update provided at the virtual Pediatric Hospital Medicine.

In pediatrics, a specialty in which approximately 70% of physicians are now women, there has been progress, but still less than 30% of pediatric department chairs are female, said Vincent Chiang, MD, chief medical officer of Boston Children’s Hospital, during a presentation at the virtual meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Citing published data and a survey he personally conducted of the top children’s hospitals identified by the U.S. News and World Report, Dr. Chiang said a minority of division chiefs, chief medical officers, chief financial officers, and other leaders are female. At his institution, only 2 of 16 division chiefs are female.

“No matter how you slice it, women are underrepresented in leadership positions,” he noted.

The problem is certainly not confined to medicine. Dr. Chiang cited data showing that women and men have reached “near parity” in workforce participation in the United States even though the 20% earnings gap has changed little over time.

According to 2020 data from the World Economic Forum, the United States ranked 51 for the gender gap calculated on the basis of economic, political, educational, and health attainment. Even if this places the United States in the top third of the rankings, it is far behind Iceland and the Scandinavian countries that lead the list.

Efforts to reduce structural biases are part of the fix, but Dr. Chiang cautioned that fundamental changes might never occur if the plan is to wait for an approach based on meritocracy. He said that existing structural biases are “slanted away from women,” who are not necessarily granted the opportunities that are readily available to men.

“A meritocracy only works if the initial playing field was level. Otherwise, it just perpetuates the inequalities,” he said.

The problem is not a shortage of women with the skills to lead. In a study by Zenger/Folkman, a consulting company that works on leadership skill development, women performed better than men in 16 of 18 leadership categories, according to Dr. Chiang.

“There is certainly no shortage of capable women,” he noted.

Of the many issues, Dr. Chiang highlighted two. The first is the challenge of placing women on leadership pathways. This is likely to require proactive strategies, such as fast-track advancement programs that guide female candidates toward leadership roles.

The second is more nuanced. According to Dr. Chiang, women who want to assume a leadership role should think more actively about how and who is making decisions at their institution so they can position themselves appropriately. This is nuanced because “there is a certain amount of gamesmanship,” he said. The rise to leadership “has never been a pure meritocracy.”

Importantly, many of the key decisions in any institution involve money, according to Dr. Chiang. As a result, he advised those seeking leadership roles to join audit committees or otherwise take on responsibility for profit-and-loss management. Even in a nonprofit institution, “you need to make the numbers work,” he said, citing the common catchphrase: “No margin, no mission.”

However, Dr. Chiang acknowledged the many obstacles that prevent women from working their way into positions of leadership. For example, networking is important, but women are not necessarily attracted or invited to some of the social engagements, such as golf outings, where strong relationships are created.

In a survey of 100,000 people working at Fortune 500 companies, “82% of women say they feel excluded at work and much of that comes from that informal networking,” Dr. Chiang said. “Whereas 92% of men think they are not excluding women in their daily work.”

There is no single solution, but Dr. Chiang believes that concrete structural changes are needed. Female doctors remain grossly underrepresented in leadership roles even as they now represent more than half of the workforce for many specialties. Based on the need for proactive approaches outlined by Dr. Chiang, it appears unlikely that gender inequality will ever resolve itself.

Lisa S. Rotenstein, MD, who has written on fixing the gender imbalance in health care, including for the Harvard Business Review, said she agreed during an interview that structural changes are critical.

“In order to address current disparities, leaders should be thinking about how to remove both the formal and informal obstacles that prevent women and minorities from getting into the rooms where these decisions are being made,” said Dr. Rotenstein, who is an instructor in medicine at Brigham and Women’s Hospital, Harvard Medical School in Boston.

“This will need to involve sponsorship that gets women invited to the right committees or in positions with responsibility for profit-and-loss management,” she added.

Dr. Rotenstein spoke about improving “access to the pipeline” that leads to leadership roles. The ways in which women are excluded from opportunities is often subtle and difficult to penetrate without fundamental changes, she explained.

“Institutions need to understand the processes that lead to leadership roles and make the changes that allow women and minorities to participate,” she said. It is not enough to recognize the problem, according to Dr. Rotenstein.

Like Dr. Chiang, she noted that changes are needed in the methods that move underrepresented groups into leadership roles.

Dr. Chiang reported no potential conflicts of interest relevant to this study.

Since the early 2000s, approximately half of medical students in the United States – and in many years, more than half – have been women, but the proportion of women occupying leadership roles in medicine remains low, according to an update provided at the virtual Pediatric Hospital Medicine.

In pediatrics, a specialty in which approximately 70% of physicians are now women, there has been progress, but still less than 30% of pediatric department chairs are female, said Vincent Chiang, MD, chief medical officer of Boston Children’s Hospital, during a presentation at the virtual meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Citing published data and a survey he personally conducted of the top children’s hospitals identified by the U.S. News and World Report, Dr. Chiang said a minority of division chiefs, chief medical officers, chief financial officers, and other leaders are female. At his institution, only 2 of 16 division chiefs are female.

“No matter how you slice it, women are underrepresented in leadership positions,” he noted.

The problem is certainly not confined to medicine. Dr. Chiang cited data showing that women and men have reached “near parity” in workforce participation in the United States even though the 20% earnings gap has changed little over time.

According to 2020 data from the World Economic Forum, the United States ranked 51 for the gender gap calculated on the basis of economic, political, educational, and health attainment. Even if this places the United States in the top third of the rankings, it is far behind Iceland and the Scandinavian countries that lead the list.

Efforts to reduce structural biases are part of the fix, but Dr. Chiang cautioned that fundamental changes might never occur if the plan is to wait for an approach based on meritocracy. He said that existing structural biases are “slanted away from women,” who are not necessarily granted the opportunities that are readily available to men.

“A meritocracy only works if the initial playing field was level. Otherwise, it just perpetuates the inequalities,” he said.

The problem is not a shortage of women with the skills to lead. In a study by Zenger/Folkman, a consulting company that works on leadership skill development, women performed better than men in 16 of 18 leadership categories, according to Dr. Chiang.

“There is certainly no shortage of capable women,” he noted.

Of the many issues, Dr. Chiang highlighted two. The first is the challenge of placing women on leadership pathways. This is likely to require proactive strategies, such as fast-track advancement programs that guide female candidates toward leadership roles.

The second is more nuanced. According to Dr. Chiang, women who want to assume a leadership role should think more actively about how and who is making decisions at their institution so they can position themselves appropriately. This is nuanced because “there is a certain amount of gamesmanship,” he said. The rise to leadership “has never been a pure meritocracy.”

Importantly, many of the key decisions in any institution involve money, according to Dr. Chiang. As a result, he advised those seeking leadership roles to join audit committees or otherwise take on responsibility for profit-and-loss management. Even in a nonprofit institution, “you need to make the numbers work,” he said, citing the common catchphrase: “No margin, no mission.”

However, Dr. Chiang acknowledged the many obstacles that prevent women from working their way into positions of leadership. For example, networking is important, but women are not necessarily attracted or invited to some of the social engagements, such as golf outings, where strong relationships are created.

In a survey of 100,000 people working at Fortune 500 companies, “82% of women say they feel excluded at work and much of that comes from that informal networking,” Dr. Chiang said. “Whereas 92% of men think they are not excluding women in their daily work.”

There is no single solution, but Dr. Chiang believes that concrete structural changes are needed. Female doctors remain grossly underrepresented in leadership roles even as they now represent more than half of the workforce for many specialties. Based on the need for proactive approaches outlined by Dr. Chiang, it appears unlikely that gender inequality will ever resolve itself.

Lisa S. Rotenstein, MD, who has written on fixing the gender imbalance in health care, including for the Harvard Business Review, said she agreed during an interview that structural changes are critical.

“In order to address current disparities, leaders should be thinking about how to remove both the formal and informal obstacles that prevent women and minorities from getting into the rooms where these decisions are being made,” said Dr. Rotenstein, who is an instructor in medicine at Brigham and Women’s Hospital, Harvard Medical School in Boston.

“This will need to involve sponsorship that gets women invited to the right committees or in positions with responsibility for profit-and-loss management,” she added.

Dr. Rotenstein spoke about improving “access to the pipeline” that leads to leadership roles. The ways in which women are excluded from opportunities is often subtle and difficult to penetrate without fundamental changes, she explained.

“Institutions need to understand the processes that lead to leadership roles and make the changes that allow women and minorities to participate,” she said. It is not enough to recognize the problem, according to Dr. Rotenstein.

Like Dr. Chiang, she noted that changes are needed in the methods that move underrepresented groups into leadership roles.

Dr. Chiang reported no potential conflicts of interest relevant to this study.