Leadership Training

Chi-Cheng Huang, MD, SFHM, was recently was named one of the Notable Asian/Pacific American Physicians in U.S. History by the American Board of Internal Medicine. May was Asian/Pacific American Heritage Month. Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System (Winston-Salem, N.C.) and associate professor at Wake Forest School of Medicine.

Dr. Huang is a board-certified hospitalist and pediatrician, and he is the founder of the Bolivian Children Project, a non-profit organization that focuses on sheltering street children in La Paz and other areas of Bolivia. Dr. Huang was inspired to start the project during a year sabbatical from medical school. He worked at an orphanage and cared for children who were victims of physical abuse. The Bolivian Children Project supports those children, and Dr. Huang’s book, When Invisible Children Sing, tells their story.
 

Joshua Lenchus, DO, RPh, SFHM, has been elected president of the Florida Medical Association. It is the first time in its history that the FMA will have a DO as its president. Dr. Lenchus is a hospitalist and chief medical officer at the Broward Health Medical Center in Fort Lauderdale, Fla.

Mark V. Williams, MD, MHM, will join Washington University School of Medicine and BJC HealthCare, both in St. Louis, as professor and chief for the Division of Hospital Medicine in October 2021. Dr. Williams is currently professor and director of the Center for Health Services Research at the University of Kentucky and chief quality officer at UK HealthCare, both in Lexington.

Dr. Williams was a founding member of the Society of Hospital Medicine, one of the first two elected members of the Board of SHM, its former president, founding editor of the Journal of Hospital Medicine, and principal investigator for Project BOOST. He established the first hospitalist program at a public hospital (Grady Memorial in Atlanta) in 1998, and later became the founding chief of the Division of Hospital Medicine in 2007 at Northwestern University School of Medicine in Chicago. At the University of Kentucky, he established the Center for Health Services Research and the Division of Hospital Medicine in 2014.

At Washington University, Dr. Williams will be tasked with translating the division of hospital medicine’s scholarly work, innovation, and research into practice improvement, focusing on developing new systems of health care delivery that are patient-centered, cost effective, and provide outstanding value.
 

Jordan Messler, MD, SFHM, has been named the new chief medical officer at Glytec (Waltham, Mass.), where he has worked as executive director of clinical practice since 2018. Dr. Messler will be tasked with leading strategy and product development while also supporting efforts in quality care, customer relations, and delivery of products.

Glytec provides insulin management software across the care continuum and is touted as the only cloud-based software provider of its kind. Dr. Messler’s background includes expertise in glycemic management. In addition, he still works as a hospitalist at Morton Plant Hospitalist Group (Clearwater, Fla.).

Dr. Messler is a senior fellow with SHM and is physician editor of SHM’s official blog The Hospital Leader.
 

Tiffani Maycock, DO, recently was named to the Board of Directors for the American Board of Family Medicine. Dr. Maycock is director of the Selma Family Medicine Residency Program at the University of Alabama at Birmingham, where she is an assistant professor in the department of family medicine.

Dr. Maycock helped create hospitalist services at Vaughan Regional Medical Center (Selma, Ala.) – Selma Family Medicine’s primary teaching site – and currently serves as its hospitalist director and on its Medical Executive Committee. She has worked at the facility since 2017.
 

Preetham Talari, MD, SFHM, has been named associate chief of quality safety for the Division of Hospital Medicine at the University of Kentucky’s UK HealthCare (Lexington, Ky.). Dr. Talari is an associate professor of internal medicine in the Division of Hospital Medicine at the UK College of Medicine.

Over the last decade, Dr. Talari’s work in quality, safety, and health care leadership has positioned him as a leader in several UK Healthcare committees and transformation projects. In his role as associate chief, Dr. Talari collaborates with hospital medicine directors, enterprise leadership, and medical education leadership to improve the system’s quality of care.

Dr. Talari is the president of the Kentucky chapter of SHM and is a member of SHM’s Hospital Quality and Patient Safety Committee.
 

Adrian Paraschiv, MD, FHM, is being recognized by Continental Who’s Who as a Trusted Internist and Hospitalist in the field of Medicine in acknowledgment of his commitment to providing quality health care services.

Dr. Paraschiv is a board-certified Internist at Garnet Health Medical Center in Middletown, N.Y. He also serves in an administrative capacity as the Garnet Health Doctors Hospitalist Division’s Associate Program Director. He is also the Director of Clinical Informatics. Dr. Paraschiv is certified as the Epic physician builder in analytics, information technology, and improved documentation.
 

DCH Health System (Tuscaloosa, Ala.) recently selected Capstone Health Services Foundation (Tuscaloosa) and IN Compass Health Inc. (Alpharetta, Ga.) as its joint hospitalist service provider for facilities in Northport and Tuscaloosa. Capstone will provide the physicians, while IN Compass will handle staffing management of the hospitalists, as well as day-to-day operations and calculating quality care metrics. The agreement is slated to begin on Oct. 1, 2021, at Northport Medical Center, and on Nov. 1, 2021, at DCH Regional Medical Center.

Capstone is an affiliate of the University of Alabama and oversees University Hospitalist Group, which currently provides hospitalists at DCH Regional Medical Center. Its partnership with IN Compass includes working together in recruiting and hiring physicians for both facilities.
 

UPMC Kane Medical Center (Kane, Pa.) recently announced the creation of a virtual telemedicine hospitalist program. UPMC Kane is partnering with the UPMC Center for Community Hospitalist Medicine to create this new mode of care.

Telehospitalists will care for UPMC Kane patients using advanced diagnostic technique and high-definition cameras. The physicians will bring expert service to Kane 24 hours per day utilizing physicians and specialists based in Pittsburgh. Those hospitalists will work with local nurse practitioners and support staff and deliver care to Kane patients.
 

Wake Forest Baptist Health (Winston-Salem, N.C.) has launched a Hospitalist at Home program with hopes of keeping patients safe while also reducing time they spend in the hospital. The telehealth initiative kicked into gear at the start of 2021 and considered the first of its kind in the region.

Patients who qualify for the program establish a plan before they leave the hospital. Wake Forest Baptist Health paramedics makes home visits and conducts care with a hospitalist reviewing the visit virtually. Those appointments continue until the patient does not require monitoring.

The impetus of creating the program was the COVID-19 pandemic, however, Wake Forest said it expects to care for between 75-100 patients through Hospitalist at Home at any one time.

Chi-Cheng Huang, MD, SFHM, was recently was named one of the Notable Asian/Pacific American Physicians in U.S. History by the American Board of Internal Medicine. May was Asian/Pacific American Heritage Month. Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System (Winston-Salem, N.C.) and associate professor at Wake Forest School of Medicine.

Dr. Huang is a board-certified hospitalist and pediatrician, and he is the founder of the Bolivian Children Project, a non-profit organization that focuses on sheltering street children in La Paz and other areas of Bolivia. Dr. Huang was inspired to start the project during a year sabbatical from medical school. He worked at an orphanage and cared for children who were victims of physical abuse. The Bolivian Children Project supports those children, and Dr. Huang’s book, When Invisible Children Sing, tells their story.
 

Joshua Lenchus, DO, RPh, SFHM, has been elected president of the Florida Medical Association. It is the first time in its history that the FMA will have a DO as its president. Dr. Lenchus is a hospitalist and chief medical officer at the Broward Health Medical Center in Fort Lauderdale, Fla.

Mark V. Williams, MD, MHM, will join Washington University School of Medicine and BJC HealthCare, both in St. Louis, as professor and chief for the Division of Hospital Medicine in October 2021. Dr. Williams is currently professor and director of the Center for Health Services Research at the University of Kentucky and chief quality officer at UK HealthCare, both in Lexington.

Dr. Williams was a founding member of the Society of Hospital Medicine, one of the first two elected members of the Board of SHM, its former president, founding editor of the Journal of Hospital Medicine, and principal investigator for Project BOOST. He established the first hospitalist program at a public hospital (Grady Memorial in Atlanta) in 1998, and later became the founding chief of the Division of Hospital Medicine in 2007 at Northwestern University School of Medicine in Chicago. At the University of Kentucky, he established the Center for Health Services Research and the Division of Hospital Medicine in 2014.

At Washington University, Dr. Williams will be tasked with translating the division of hospital medicine’s scholarly work, innovation, and research into practice improvement, focusing on developing new systems of health care delivery that are patient-centered, cost effective, and provide outstanding value.
 

Jordan Messler, MD, SFHM, has been named the new chief medical officer at Glytec (Waltham, Mass.), where he has worked as executive director of clinical practice since 2018. Dr. Messler will be tasked with leading strategy and product development while also supporting efforts in quality care, customer relations, and delivery of products.

Glytec provides insulin management software across the care continuum and is touted as the only cloud-based software provider of its kind. Dr. Messler’s background includes expertise in glycemic management. In addition, he still works as a hospitalist at Morton Plant Hospitalist Group (Clearwater, Fla.).

Dr. Messler is a senior fellow with SHM and is physician editor of SHM’s official blog The Hospital Leader.
 

Tiffani Maycock, DO, recently was named to the Board of Directors for the American Board of Family Medicine. Dr. Maycock is director of the Selma Family Medicine Residency Program at the University of Alabama at Birmingham, where she is an assistant professor in the department of family medicine.

Dr. Maycock helped create hospitalist services at Vaughan Regional Medical Center (Selma, Ala.) – Selma Family Medicine’s primary teaching site – and currently serves as its hospitalist director and on its Medical Executive Committee. She has worked at the facility since 2017.
 

Preetham Talari, MD, SFHM, has been named associate chief of quality safety for the Division of Hospital Medicine at the University of Kentucky’s UK HealthCare (Lexington, Ky.). Dr. Talari is an associate professor of internal medicine in the Division of Hospital Medicine at the UK College of Medicine.

Over the last decade, Dr. Talari’s work in quality, safety, and health care leadership has positioned him as a leader in several UK Healthcare committees and transformation projects. In his role as associate chief, Dr. Talari collaborates with hospital medicine directors, enterprise leadership, and medical education leadership to improve the system’s quality of care.

Dr. Talari is the president of the Kentucky chapter of SHM and is a member of SHM’s Hospital Quality and Patient Safety Committee.
 

Adrian Paraschiv, MD, FHM, is being recognized by Continental Who’s Who as a Trusted Internist and Hospitalist in the field of Medicine in acknowledgment of his commitment to providing quality health care services.

Dr. Paraschiv is a board-certified Internist at Garnet Health Medical Center in Middletown, N.Y. He also serves in an administrative capacity as the Garnet Health Doctors Hospitalist Division’s Associate Program Director. He is also the Director of Clinical Informatics. Dr. Paraschiv is certified as the Epic physician builder in analytics, information technology, and improved documentation.
 

DCH Health System (Tuscaloosa, Ala.) recently selected Capstone Health Services Foundation (Tuscaloosa) and IN Compass Health Inc. (Alpharetta, Ga.) as its joint hospitalist service provider for facilities in Northport and Tuscaloosa. Capstone will provide the physicians, while IN Compass will handle staffing management of the hospitalists, as well as day-to-day operations and calculating quality care metrics. The agreement is slated to begin on Oct. 1, 2021, at Northport Medical Center, and on Nov. 1, 2021, at DCH Regional Medical Center.

Capstone is an affiliate of the University of Alabama and oversees University Hospitalist Group, which currently provides hospitalists at DCH Regional Medical Center. Its partnership with IN Compass includes working together in recruiting and hiring physicians for both facilities.
 

UPMC Kane Medical Center (Kane, Pa.) recently announced the creation of a virtual telemedicine hospitalist program. UPMC Kane is partnering with the UPMC Center for Community Hospitalist Medicine to create this new mode of care.

Telehospitalists will care for UPMC Kane patients using advanced diagnostic technique and high-definition cameras. The physicians will bring expert service to Kane 24 hours per day utilizing physicians and specialists based in Pittsburgh. Those hospitalists will work with local nurse practitioners and support staff and deliver care to Kane patients.
 

Wake Forest Baptist Health (Winston-Salem, N.C.) has launched a Hospitalist at Home program with hopes of keeping patients safe while also reducing time they spend in the hospital. The telehealth initiative kicked into gear at the start of 2021 and considered the first of its kind in the region.

Patients who qualify for the program establish a plan before they leave the hospital. Wake Forest Baptist Health paramedics makes home visits and conducts care with a hospitalist reviewing the visit virtually. Those appointments continue until the patient does not require monitoring.

The impetus of creating the program was the COVID-19 pandemic, however, Wake Forest said it expects to care for between 75-100 patients through Hospitalist at Home at any one time.

Chi-Cheng Huang, MD, SFHM, was recently was named one of the Notable Asian/Pacific American Physicians in U.S. History by the American Board of Internal Medicine. May was Asian/Pacific American Heritage Month. Dr. Huang is the executive medical director and service line director of general medicine and hospital medicine within the Wake Forest Baptist Health System (Winston-Salem, N.C.) and associate professor at Wake Forest School of Medicine.

Dr. Huang is a board-certified hospitalist and pediatrician, and he is the founder of the Bolivian Children Project, a non-profit organization that focuses on sheltering street children in La Paz and other areas of Bolivia. Dr. Huang was inspired to start the project during a year sabbatical from medical school. He worked at an orphanage and cared for children who were victims of physical abuse. The Bolivian Children Project supports those children, and Dr. Huang’s book, When Invisible Children Sing, tells their story.
 

Joshua Lenchus, DO, RPh, SFHM, has been elected president of the Florida Medical Association. It is the first time in its history that the FMA will have a DO as its president. Dr. Lenchus is a hospitalist and chief medical officer at the Broward Health Medical Center in Fort Lauderdale, Fla.

Mark V. Williams, MD, MHM, will join Washington University School of Medicine and BJC HealthCare, both in St. Louis, as professor and chief for the Division of Hospital Medicine in October 2021. Dr. Williams is currently professor and director of the Center for Health Services Research at the University of Kentucky and chief quality officer at UK HealthCare, both in Lexington.

Dr. Williams was a founding member of the Society of Hospital Medicine, one of the first two elected members of the Board of SHM, its former president, founding editor of the Journal of Hospital Medicine, and principal investigator for Project BOOST. He established the first hospitalist program at a public hospital (Grady Memorial in Atlanta) in 1998, and later became the founding chief of the Division of Hospital Medicine in 2007 at Northwestern University School of Medicine in Chicago. At the University of Kentucky, he established the Center for Health Services Research and the Division of Hospital Medicine in 2014.

At Washington University, Dr. Williams will be tasked with translating the division of hospital medicine’s scholarly work, innovation, and research into practice improvement, focusing on developing new systems of health care delivery that are patient-centered, cost effective, and provide outstanding value.
 

Jordan Messler, MD, SFHM, has been named the new chief medical officer at Glytec (Waltham, Mass.), where he has worked as executive director of clinical practice since 2018. Dr. Messler will be tasked with leading strategy and product development while also supporting efforts in quality care, customer relations, and delivery of products.

Glytec provides insulin management software across the care continuum and is touted as the only cloud-based software provider of its kind. Dr. Messler’s background includes expertise in glycemic management. In addition, he still works as a hospitalist at Morton Plant Hospitalist Group (Clearwater, Fla.).

Dr. Messler is a senior fellow with SHM and is physician editor of SHM’s official blog The Hospital Leader.
 

Tiffani Maycock, DO, recently was named to the Board of Directors for the American Board of Family Medicine. Dr. Maycock is director of the Selma Family Medicine Residency Program at the University of Alabama at Birmingham, where she is an assistant professor in the department of family medicine.

Dr. Maycock helped create hospitalist services at Vaughan Regional Medical Center (Selma, Ala.) – Selma Family Medicine’s primary teaching site – and currently serves as its hospitalist director and on its Medical Executive Committee. She has worked at the facility since 2017.
 

Preetham Talari, MD, SFHM, has been named associate chief of quality safety for the Division of Hospital Medicine at the University of Kentucky’s UK HealthCare (Lexington, Ky.). Dr. Talari is an associate professor of internal medicine in the Division of Hospital Medicine at the UK College of Medicine.

Over the last decade, Dr. Talari’s work in quality, safety, and health care leadership has positioned him as a leader in several UK Healthcare committees and transformation projects. In his role as associate chief, Dr. Talari collaborates with hospital medicine directors, enterprise leadership, and medical education leadership to improve the system’s quality of care.

Dr. Talari is the president of the Kentucky chapter of SHM and is a member of SHM’s Hospital Quality and Patient Safety Committee.
 

Adrian Paraschiv, MD, FHM, is being recognized by Continental Who’s Who as a Trusted Internist and Hospitalist in the field of Medicine in acknowledgment of his commitment to providing quality health care services.

Dr. Paraschiv is a board-certified Internist at Garnet Health Medical Center in Middletown, N.Y. He also serves in an administrative capacity as the Garnet Health Doctors Hospitalist Division’s Associate Program Director. He is also the Director of Clinical Informatics. Dr. Paraschiv is certified as the Epic physician builder in analytics, information technology, and improved documentation.
 

DCH Health System (Tuscaloosa, Ala.) recently selected Capstone Health Services Foundation (Tuscaloosa) and IN Compass Health Inc. (Alpharetta, Ga.) as its joint hospitalist service provider for facilities in Northport and Tuscaloosa. Capstone will provide the physicians, while IN Compass will handle staffing management of the hospitalists, as well as day-to-day operations and calculating quality care metrics. The agreement is slated to begin on Oct. 1, 2021, at Northport Medical Center, and on Nov. 1, 2021, at DCH Regional Medical Center.

Capstone is an affiliate of the University of Alabama and oversees University Hospitalist Group, which currently provides hospitalists at DCH Regional Medical Center. Its partnership with IN Compass includes working together in recruiting and hiring physicians for both facilities.
 

UPMC Kane Medical Center (Kane, Pa.) recently announced the creation of a virtual telemedicine hospitalist program. UPMC Kane is partnering with the UPMC Center for Community Hospitalist Medicine to create this new mode of care.

Telehospitalists will care for UPMC Kane patients using advanced diagnostic technique and high-definition cameras. The physicians will bring expert service to Kane 24 hours per day utilizing physicians and specialists based in Pittsburgh. Those hospitalists will work with local nurse practitioners and support staff and deliver care to Kane patients.
 

Wake Forest Baptist Health (Winston-Salem, N.C.) has launched a Hospitalist at Home program with hopes of keeping patients safe while also reducing time they spend in the hospital. The telehealth initiative kicked into gear at the start of 2021 and considered the first of its kind in the region.

Patients who qualify for the program establish a plan before they leave the hospital. Wake Forest Baptist Health paramedics makes home visits and conducts care with a hospitalist reviewing the visit virtually. Those appointments continue until the patient does not require monitoring.

The impetus of creating the program was the COVID-19 pandemic, however, Wake Forest said it expects to care for between 75-100 patients through Hospitalist at Home at any one time.

Growth mindset is a well-established phenomenon in childhood education that is now starting to appear in health care education literature.¹ This concept emphasizes the capacity of individuals to change and grow through experience and that an individual’s basic qualities can be cultivated through hard work, open-mindedness, and help from others.²

Herchline_Daniel_OHIO_web.jpg

Growth mindset opposes the concept of fixed mindset, which implies intelligence or other personal traits are set in stone, unable to be fundamentally changed.² Individuals with fixed mindsets are less adept at coping with perceived failures and critical feedback because they view these as attacks on their own abilities.² This oftentimes leads these individuals to avoid potential challenges and feedback because of fear of being exposed as incompetent or feeling inadequate. Conversely, individuals with a growth mindset embrace challenges and failures as learning opportunities and identify feedback as a critical element of growth.² These individuals maintain a sense of resilience in the face of adversity and strive to become lifelong learners.

As the field of pediatric hospital medicine (PHM) continues to rapidly evolve, so too does the landscape of PHM fellowships. New programs are opening at a torrid pace to accommodate the increasing demand of residents looking to enter the field with new subspecialty accreditation. Most first-year PHM fellows in established programs enter with a clear precedent to follow, set forth by fellows who have come before them. For PHM fellows in new programs, however, there is often no beaten path to follow.

Entering fellowship as a first-year PHM fellow in a new program and blazing one’s own trail can be intriguing and exhilarating given the unique opportunities available. However, the potential challenges for both fellows and program directors during this transition cannot be understated. The role of new PHM fellows within the institutional framework may initially be unclear to others, which can lead to ambiguous expectations and disruptions to normal workflows. Furthermore, assessing and evaluating new fellows may prove difficult as a result of these unclear expectations and general uncertainties. Using the growth mindset can help both PHM fellows and program directors take a deliberate approach to the challenges and uncertainty that may accompany the creation of a new fellowship program.

One of the challenges new PHM fellows may encounter lies within the structure of the care team. Resident and medical student learners may express consternation that the new fellow role may limit their own autonomy. In addition, finding the right balance of autonomy and supervision between the attending-fellow dyad may prove to be difficult. However, using the growth mindset may allow fellows to see the inherent benefits of this new role.

Fellows should seize the opportunity to discuss the nuances and differing approaches to difficult clinical questions, managing a team and interpersonal dynamics, and balancing clinical and nonclinical responsibilities with an experienced supervising clinician; issues that are often less pressing as a resident. The fellow role also affords the opportunity to more carefully observe different clinical styles of practice to subsequently shape one’s own preferred style.

Finally, fellows should employ a growth mindset to optimize clinical time by discussing expectations with involved stakeholders prior to rotations and explicitly identifying goals for feedback and improvement. Program directors can also help stakeholders including faculty, residency programs, medical schools, and other health care professionals on the clinical teams prepare for this transition by providing expectations for the fellow role and by soliciting questions and feedback before and after fellows begin.

One of the key tenets of the growth mindset is actively seeking out constructive feedback and learning from failures to grow and improve. This can be a particularly useful practice for fellows during the course of their scholarly pursuits in clinical research, quality improvement, and medical education. From initial stages of idea development through the final steps of manuscript submission and peer review, fellows will undoubtedly navigate a plethora of challenges and setbacks along the way. Program directors and other core faculty members can promote a growth mindset culture by honestly discussing their own challenges and failures in career endeavors in addition to giving thoughtful constructive feedback.

Fellows should routinely practice explicitly identifying knowledge and skills gaps that represent areas for potential improvement. But perhaps most importantly, fellows must strive to see all feedback and perceived failures not as personal affronts or as commentaries on personal abilities, but rather as opportunities to strengthen their scholarly products and gain valuable experience for future endeavors.

Not all learners will come equipped with a growth mindset. So, what can fellows and program directors in new programs do to develop this practice and mitigate some of the inevitable uncertainty? To begin, program directors should think about how to create cultures of growth and development as the fixed and growth mindsets are not just limited to individuals.³ Program directors can strive to augment this process by committing to solicit feedback for themselves and acknowledging their own vulnerabilities and perceived weaknesses.

Fellows must have early, honest discussions with program directors and other stakeholders about expectations and goals. Program directors should consider creating lists of “must meet” individuals within the institution that can help fellows begin to carve out their roles in the clinical, educational, and research realms. Deliberately crafting a mentorship team that will encourage a commitment to growth and improvement is critical. Seeking out growth feedback, particularly in areas that prove challenging, should become common practice for fellows from the onset.

Most importantly, fellows should reframe uncertainty as opportunity for growth and progression. Seeing oneself as a work in progress provides a new perspective that prioritizes learning and emphasizes improvement potential.

Embodying this approach requires patience and practice. Being part of a newly created fellowship represents an opportunity to learn from personal challenges rather than leaning on the precedent set by previous fellows. And although fellows will often face uncertainty as a part of the novelty within a new program, they can ultimately succeed by practicing the principles of Dweck’s Growth Mindset: embracing challenges and failure as learning experiences, seeking out feedback, and pursuing the opportunities among ambiguity.
 

Dr. Herchline is a pediatric hospitalist at Cincinnati Children’s Hospital Medical Center and recent fellow graduate of the Children’s Hospital of Philadelphia. During fellowship, he completed a master’s degree in medical education at the University of Pennsylvania. His academic interests include graduate medical education, interprofessional collaboration and teamwork, and quality improvement.

References

1. Klein J et al. A growth mindset approach to preparing trainees for medical error. BMJ Qual Saf. 2017 Sep;26(9):771-4. doi: 10.1136/bmjqs-2016-006416.

2. Dweck C. Mindset: The new psychology of success. New York: Ballantine Books; 2006.

3. Murphy MC, Dweck CS. A culture of genius: How an organization’s lay theory shapes people’s cognition, affect, and behavior. Pers Soc Psychol Bull. 2010 Mar;36(3):283-96. doi: 10.1177/0146167209347380.

Growth mindset is a well-established phenomenon in childhood education that is now starting to appear in health care education literature.¹ This concept emphasizes the capacity of individuals to change and grow through experience and that an individual’s basic qualities can be cultivated through hard work, open-mindedness, and help from others.²

Herchline_Daniel_OHIO_web.jpg

Growth mindset opposes the concept of fixed mindset, which implies intelligence or other personal traits are set in stone, unable to be fundamentally changed.² Individuals with fixed mindsets are less adept at coping with perceived failures and critical feedback because they view these as attacks on their own abilities.² This oftentimes leads these individuals to avoid potential challenges and feedback because of fear of being exposed as incompetent or feeling inadequate. Conversely, individuals with a growth mindset embrace challenges and failures as learning opportunities and identify feedback as a critical element of growth.² These individuals maintain a sense of resilience in the face of adversity and strive to become lifelong learners.

As the field of pediatric hospital medicine (PHM) continues to rapidly evolve, so too does the landscape of PHM fellowships. New programs are opening at a torrid pace to accommodate the increasing demand of residents looking to enter the field with new subspecialty accreditation. Most first-year PHM fellows in established programs enter with a clear precedent to follow, set forth by fellows who have come before them. For PHM fellows in new programs, however, there is often no beaten path to follow.

Entering fellowship as a first-year PHM fellow in a new program and blazing one’s own trail can be intriguing and exhilarating given the unique opportunities available. However, the potential challenges for both fellows and program directors during this transition cannot be understated. The role of new PHM fellows within the institutional framework may initially be unclear to others, which can lead to ambiguous expectations and disruptions to normal workflows. Furthermore, assessing and evaluating new fellows may prove difficult as a result of these unclear expectations and general uncertainties. Using the growth mindset can help both PHM fellows and program directors take a deliberate approach to the challenges and uncertainty that may accompany the creation of a new fellowship program.

One of the challenges new PHM fellows may encounter lies within the structure of the care team. Resident and medical student learners may express consternation that the new fellow role may limit their own autonomy. In addition, finding the right balance of autonomy and supervision between the attending-fellow dyad may prove to be difficult. However, using the growth mindset may allow fellows to see the inherent benefits of this new role.

Fellows should seize the opportunity to discuss the nuances and differing approaches to difficult clinical questions, managing a team and interpersonal dynamics, and balancing clinical and nonclinical responsibilities with an experienced supervising clinician; issues that are often less pressing as a resident. The fellow role also affords the opportunity to more carefully observe different clinical styles of practice to subsequently shape one’s own preferred style.

Finally, fellows should employ a growth mindset to optimize clinical time by discussing expectations with involved stakeholders prior to rotations and explicitly identifying goals for feedback and improvement. Program directors can also help stakeholders including faculty, residency programs, medical schools, and other health care professionals on the clinical teams prepare for this transition by providing expectations for the fellow role and by soliciting questions and feedback before and after fellows begin.

One of the key tenets of the growth mindset is actively seeking out constructive feedback and learning from failures to grow and improve. This can be a particularly useful practice for fellows during the course of their scholarly pursuits in clinical research, quality improvement, and medical education. From initial stages of idea development through the final steps of manuscript submission and peer review, fellows will undoubtedly navigate a plethora of challenges and setbacks along the way. Program directors and other core faculty members can promote a growth mindset culture by honestly discussing their own challenges and failures in career endeavors in addition to giving thoughtful constructive feedback.

Fellows should routinely practice explicitly identifying knowledge and skills gaps that represent areas for potential improvement. But perhaps most importantly, fellows must strive to see all feedback and perceived failures not as personal affronts or as commentaries on personal abilities, but rather as opportunities to strengthen their scholarly products and gain valuable experience for future endeavors.

Not all learners will come equipped with a growth mindset. So, what can fellows and program directors in new programs do to develop this practice and mitigate some of the inevitable uncertainty? To begin, program directors should think about how to create cultures of growth and development as the fixed and growth mindsets are not just limited to individuals.³ Program directors can strive to augment this process by committing to solicit feedback for themselves and acknowledging their own vulnerabilities and perceived weaknesses.

Fellows must have early, honest discussions with program directors and other stakeholders about expectations and goals. Program directors should consider creating lists of “must meet” individuals within the institution that can help fellows begin to carve out their roles in the clinical, educational, and research realms. Deliberately crafting a mentorship team that will encourage a commitment to growth and improvement is critical. Seeking out growth feedback, particularly in areas that prove challenging, should become common practice for fellows from the onset.

Most importantly, fellows should reframe uncertainty as opportunity for growth and progression. Seeing oneself as a work in progress provides a new perspective that prioritizes learning and emphasizes improvement potential.

Embodying this approach requires patience and practice. Being part of a newly created fellowship represents an opportunity to learn from personal challenges rather than leaning on the precedent set by previous fellows. And although fellows will often face uncertainty as a part of the novelty within a new program, they can ultimately succeed by practicing the principles of Dweck’s Growth Mindset: embracing challenges and failure as learning experiences, seeking out feedback, and pursuing the opportunities among ambiguity.
 

Dr. Herchline is a pediatric hospitalist at Cincinnati Children’s Hospital Medical Center and recent fellow graduate of the Children’s Hospital of Philadelphia. During fellowship, he completed a master’s degree in medical education at the University of Pennsylvania. His academic interests include graduate medical education, interprofessional collaboration and teamwork, and quality improvement.

References

1. Klein J et al. A growth mindset approach to preparing trainees for medical error. BMJ Qual Saf. 2017 Sep;26(9):771-4. doi: 10.1136/bmjqs-2016-006416.

2. Dweck C. Mindset: The new psychology of success. New York: Ballantine Books; 2006.

3. Murphy MC, Dweck CS. A culture of genius: How an organization’s lay theory shapes people’s cognition, affect, and behavior. Pers Soc Psychol Bull. 2010 Mar;36(3):283-96. doi: 10.1177/0146167209347380.

Growth mindset is a well-established phenomenon in childhood education that is now starting to appear in health care education literature.¹ This concept emphasizes the capacity of individuals to change and grow through experience and that an individual’s basic qualities can be cultivated through hard work, open-mindedness, and help from others.²

Herchline_Daniel_OHIO_web.jpg

Growth mindset opposes the concept of fixed mindset, which implies intelligence or other personal traits are set in stone, unable to be fundamentally changed.² Individuals with fixed mindsets are less adept at coping with perceived failures and critical feedback because they view these as attacks on their own abilities.² This oftentimes leads these individuals to avoid potential challenges and feedback because of fear of being exposed as incompetent or feeling inadequate. Conversely, individuals with a growth mindset embrace challenges and failures as learning opportunities and identify feedback as a critical element of growth.² These individuals maintain a sense of resilience in the face of adversity and strive to become lifelong learners.

As the field of pediatric hospital medicine (PHM) continues to rapidly evolve, so too does the landscape of PHM fellowships. New programs are opening at a torrid pace to accommodate the increasing demand of residents looking to enter the field with new subspecialty accreditation. Most first-year PHM fellows in established programs enter with a clear precedent to follow, set forth by fellows who have come before them. For PHM fellows in new programs, however, there is often no beaten path to follow.

Entering fellowship as a first-year PHM fellow in a new program and blazing one’s own trail can be intriguing and exhilarating given the unique opportunities available. However, the potential challenges for both fellows and program directors during this transition cannot be understated. The role of new PHM fellows within the institutional framework may initially be unclear to others, which can lead to ambiguous expectations and disruptions to normal workflows. Furthermore, assessing and evaluating new fellows may prove difficult as a result of these unclear expectations and general uncertainties. Using the growth mindset can help both PHM fellows and program directors take a deliberate approach to the challenges and uncertainty that may accompany the creation of a new fellowship program.

One of the challenges new PHM fellows may encounter lies within the structure of the care team. Resident and medical student learners may express consternation that the new fellow role may limit their own autonomy. In addition, finding the right balance of autonomy and supervision between the attending-fellow dyad may prove to be difficult. However, using the growth mindset may allow fellows to see the inherent benefits of this new role.

Fellows should seize the opportunity to discuss the nuances and differing approaches to difficult clinical questions, managing a team and interpersonal dynamics, and balancing clinical and nonclinical responsibilities with an experienced supervising clinician; issues that are often less pressing as a resident. The fellow role also affords the opportunity to more carefully observe different clinical styles of practice to subsequently shape one’s own preferred style.

Finally, fellows should employ a growth mindset to optimize clinical time by discussing expectations with involved stakeholders prior to rotations and explicitly identifying goals for feedback and improvement. Program directors can also help stakeholders including faculty, residency programs, medical schools, and other health care professionals on the clinical teams prepare for this transition by providing expectations for the fellow role and by soliciting questions and feedback before and after fellows begin.

One of the key tenets of the growth mindset is actively seeking out constructive feedback and learning from failures to grow and improve. This can be a particularly useful practice for fellows during the course of their scholarly pursuits in clinical research, quality improvement, and medical education. From initial stages of idea development through the final steps of manuscript submission and peer review, fellows will undoubtedly navigate a plethora of challenges and setbacks along the way. Program directors and other core faculty members can promote a growth mindset culture by honestly discussing their own challenges and failures in career endeavors in addition to giving thoughtful constructive feedback.

Fellows should routinely practice explicitly identifying knowledge and skills gaps that represent areas for potential improvement. But perhaps most importantly, fellows must strive to see all feedback and perceived failures not as personal affronts or as commentaries on personal abilities, but rather as opportunities to strengthen their scholarly products and gain valuable experience for future endeavors.

Not all learners will come equipped with a growth mindset. So, what can fellows and program directors in new programs do to develop this practice and mitigate some of the inevitable uncertainty? To begin, program directors should think about how to create cultures of growth and development as the fixed and growth mindsets are not just limited to individuals.³ Program directors can strive to augment this process by committing to solicit feedback for themselves and acknowledging their own vulnerabilities and perceived weaknesses.

Fellows must have early, honest discussions with program directors and other stakeholders about expectations and goals. Program directors should consider creating lists of “must meet” individuals within the institution that can help fellows begin to carve out their roles in the clinical, educational, and research realms. Deliberately crafting a mentorship team that will encourage a commitment to growth and improvement is critical. Seeking out growth feedback, particularly in areas that prove challenging, should become common practice for fellows from the onset.

Most importantly, fellows should reframe uncertainty as opportunity for growth and progression. Seeing oneself as a work in progress provides a new perspective that prioritizes learning and emphasizes improvement potential.

Embodying this approach requires patience and practice. Being part of a newly created fellowship represents an opportunity to learn from personal challenges rather than leaning on the precedent set by previous fellows. And although fellows will often face uncertainty as a part of the novelty within a new program, they can ultimately succeed by practicing the principles of Dweck’s Growth Mindset: embracing challenges and failure as learning experiences, seeking out feedback, and pursuing the opportunities among ambiguity.
 

Dr. Herchline is a pediatric hospitalist at Cincinnati Children’s Hospital Medical Center and recent fellow graduate of the Children’s Hospital of Philadelphia. During fellowship, he completed a master’s degree in medical education at the University of Pennsylvania. His academic interests include graduate medical education, interprofessional collaboration and teamwork, and quality improvement.

References

1. Klein J et al. A growth mindset approach to preparing trainees for medical error. BMJ Qual Saf. 2017 Sep;26(9):771-4. doi: 10.1136/bmjqs-2016-006416.

2. Dweck C. Mindset: The new psychology of success. New York: Ballantine Books; 2006.

3. Murphy MC, Dweck CS. A culture of genius: How an organization’s lay theory shapes people’s cognition, affect, and behavior. Pers Soc Psychol Bull. 2010 Mar;36(3):283-96. doi: 10.1177/0146167209347380.

Let me apologize for misleading all of you; this is not an article about malignant physician leaders; instead, it goes over the numbers and trends uncovered by the 2020 State of Hospital Medicine report (SoHM).¹ The hospital medicine leader ends up doing many tasks like planning, growth, collaboration, finance, recruiting, scheduling, onboarding, coaching, and most near and dear to our hearts, putting out the fires and conflict resolution.

Chadha_Ramil_KY_web.jpg

Ratio of leadership FTE to physician hospitalists FTE

If my pun has already put you off, you can avoid reading the rest of the piece and go to the 2020 SoHM to look at pages 52 (Table 3.7c), 121 (Table 4.7c), and 166 (Table 5.7c). It has a newly added table (3.7c), and it is phenomenal; it is the ratio of leadership FTE to physician hospitalists FTE. As an avid user of SoHM, I always ended up doing a makeshift calculation to “guesstimate” this number. Now that we have it calculated for us and the ultimate revelation lies in its narrow range across all groups. We might differ in the region, employment type, academics, teaching, or size, but this range is relatively narrow.

153365_graph 1_web.jpg

The median ratio of leadership FTE to total FTE lies between 2% and 5% in pediatric groups and between 3% and 6% for most adult groups. The only two outliers are on the adult side, with less than 5 FTE and multistate management companies. The higher median for the less than 5 FTE group size is understandable because of the small number of hospitalist FTEs that the leader’s time must be spread over. Even a small amount of dedicated leadership time will result in a high ratio of leader time to hospitalist clinical time if the group is very small. The multistate management company is probably a result of multiple layers of physician leadership (for example, regional medical directors) and travel-related time adjustments. Still, it raises the question of why the local leadership is not developed to decrease the leadership cost and better access.

Another helpful pattern is the decrease in standard deviation with the increase in group size. The hospital medicine leaders and CEOs of the hospital need to watch this number closely; any extremes on high or low side would be indicators for a deep dive in leadership structure and health.
 

Total number and total dedicated FTE for all physician leaders

Once we start seeing the differences between the mean and median of leadership data, we can see the median is relatively static while the mean has increased year after year and took a big jump in the 2020 SoHM. The chart below shows trends for the number of individuals in leadership positions (“Total No” and total FTEs allocated to leadership (“Total FTE”) over the last several surveys. The data is heavily skewed toward the right (positive); so, it makes sense to use the median in this case rather than mean. A few factors could explain the right skew of data.

• Large groups of 30 or more hospitalists are increasing, and so is their leadership need.
• There is more recognition of the need for dedicated leadership individuals and FTE.
• The leadership is getting less concentrated among just one or a few leaders.
• Outliers on the high side.
• Lower bounds of 0 or 0.1 FTE.

Highest-ranked leader dedicated FTE and premium compensation

Another pleasing trend is an increase in dedicated FTE for the highest-paid leader. Like any skill-set development, leadership requires the investment of deliberate practice, financial acumen, negotiation skills, and increased vulnerability. Time helps way more in developing these skill sets than money. SoHM trends show increase in dedicated FTE for the highest physician leader over the years and static premium compensation.

153365_Graph 3_web.jpg

At last, we can say median leadership is always better than “mean” leadership in skewed data. Pun apart, every group needs leadership, and SoHM offers a nice window to the trends in leadership amongst many practice groups. It is a valuable resource for every group.

Dr. Chadha is chief of the division of hospital medicine at the University of Kentucky Healthcare, Lexington. He actively leads efforts of recruiting, practice analysis, and operation of the group. He is finishing his first tenure in the Practice Analysis Committee. He is often found spending a lot more than required time with spreadsheets and graphs.

Reference

1. 2020 State of Hospital Medicine. www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/

Let me apologize for misleading all of you; this is not an article about malignant physician leaders; instead, it goes over the numbers and trends uncovered by the 2020 State of Hospital Medicine report (SoHM).¹ The hospital medicine leader ends up doing many tasks like planning, growth, collaboration, finance, recruiting, scheduling, onboarding, coaching, and most near and dear to our hearts, putting out the fires and conflict resolution.

Chadha_Ramil_KY_web.jpg

Ratio of leadership FTE to physician hospitalists FTE

If my pun has already put you off, you can avoid reading the rest of the piece and go to the 2020 SoHM to look at pages 52 (Table 3.7c), 121 (Table 4.7c), and 166 (Table 5.7c). It has a newly added table (3.7c), and it is phenomenal; it is the ratio of leadership FTE to physician hospitalists FTE. As an avid user of SoHM, I always ended up doing a makeshift calculation to “guesstimate” this number. Now that we have it calculated for us and the ultimate revelation lies in its narrow range across all groups. We might differ in the region, employment type, academics, teaching, or size, but this range is relatively narrow.

153365_graph 1_web.jpg

The median ratio of leadership FTE to total FTE lies between 2% and 5% in pediatric groups and between 3% and 6% for most adult groups. The only two outliers are on the adult side, with less than 5 FTE and multistate management companies. The higher median for the less than 5 FTE group size is understandable because of the small number of hospitalist FTEs that the leader’s time must be spread over. Even a small amount of dedicated leadership time will result in a high ratio of leader time to hospitalist clinical time if the group is very small. The multistate management company is probably a result of multiple layers of physician leadership (for example, regional medical directors) and travel-related time adjustments. Still, it raises the question of why the local leadership is not developed to decrease the leadership cost and better access.

Another helpful pattern is the decrease in standard deviation with the increase in group size. The hospital medicine leaders and CEOs of the hospital need to watch this number closely; any extremes on high or low side would be indicators for a deep dive in leadership structure and health.
 

Total number and total dedicated FTE for all physician leaders

Once we start seeing the differences between the mean and median of leadership data, we can see the median is relatively static while the mean has increased year after year and took a big jump in the 2020 SoHM. The chart below shows trends for the number of individuals in leadership positions (“Total No” and total FTEs allocated to leadership (“Total FTE”) over the last several surveys. The data is heavily skewed toward the right (positive); so, it makes sense to use the median in this case rather than mean. A few factors could explain the right skew of data.

• Large groups of 30 or more hospitalists are increasing, and so is their leadership need.
• There is more recognition of the need for dedicated leadership individuals and FTE.
• The leadership is getting less concentrated among just one or a few leaders.
• Outliers on the high side.
• Lower bounds of 0 or 0.1 FTE.

Highest-ranked leader dedicated FTE and premium compensation

Another pleasing trend is an increase in dedicated FTE for the highest-paid leader. Like any skill-set development, leadership requires the investment of deliberate practice, financial acumen, negotiation skills, and increased vulnerability. Time helps way more in developing these skill sets than money. SoHM trends show increase in dedicated FTE for the highest physician leader over the years and static premium compensation.

153365_Graph 3_web.jpg

At last, we can say median leadership is always better than “mean” leadership in skewed data. Pun apart, every group needs leadership, and SoHM offers a nice window to the trends in leadership amongst many practice groups. It is a valuable resource for every group.

Dr. Chadha is chief of the division of hospital medicine at the University of Kentucky Healthcare, Lexington. He actively leads efforts of recruiting, practice analysis, and operation of the group. He is finishing his first tenure in the Practice Analysis Committee. He is often found spending a lot more than required time with spreadsheets and graphs.

Reference

1. 2020 State of Hospital Medicine. www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/

Let me apologize for misleading all of you; this is not an article about malignant physician leaders; instead, it goes over the numbers and trends uncovered by the 2020 State of Hospital Medicine report (SoHM).¹ The hospital medicine leader ends up doing many tasks like planning, growth, collaboration, finance, recruiting, scheduling, onboarding, coaching, and most near and dear to our hearts, putting out the fires and conflict resolution.

Chadha_Ramil_KY_web.jpg

Ratio of leadership FTE to physician hospitalists FTE

If my pun has already put you off, you can avoid reading the rest of the piece and go to the 2020 SoHM to look at pages 52 (Table 3.7c), 121 (Table 4.7c), and 166 (Table 5.7c). It has a newly added table (3.7c), and it is phenomenal; it is the ratio of leadership FTE to physician hospitalists FTE. As an avid user of SoHM, I always ended up doing a makeshift calculation to “guesstimate” this number. Now that we have it calculated for us and the ultimate revelation lies in its narrow range across all groups. We might differ in the region, employment type, academics, teaching, or size, but this range is relatively narrow.

153365_graph 1_web.jpg

The median ratio of leadership FTE to total FTE lies between 2% and 5% in pediatric groups and between 3% and 6% for most adult groups. The only two outliers are on the adult side, with less than 5 FTE and multistate management companies. The higher median for the less than 5 FTE group size is understandable because of the small number of hospitalist FTEs that the leader’s time must be spread over. Even a small amount of dedicated leadership time will result in a high ratio of leader time to hospitalist clinical time if the group is very small. The multistate management company is probably a result of multiple layers of physician leadership (for example, regional medical directors) and travel-related time adjustments. Still, it raises the question of why the local leadership is not developed to decrease the leadership cost and better access.

Another helpful pattern is the decrease in standard deviation with the increase in group size. The hospital medicine leaders and CEOs of the hospital need to watch this number closely; any extremes on high or low side would be indicators for a deep dive in leadership structure and health.
 

Total number and total dedicated FTE for all physician leaders

Once we start seeing the differences between the mean and median of leadership data, we can see the median is relatively static while the mean has increased year after year and took a big jump in the 2020 SoHM. The chart below shows trends for the number of individuals in leadership positions (“Total No” and total FTEs allocated to leadership (“Total FTE”) over the last several surveys. The data is heavily skewed toward the right (positive); so, it makes sense to use the median in this case rather than mean. A few factors could explain the right skew of data.

• Large groups of 30 or more hospitalists are increasing, and so is their leadership need.
• There is more recognition of the need for dedicated leadership individuals and FTE.
• The leadership is getting less concentrated among just one or a few leaders.
• Outliers on the high side.
• Lower bounds of 0 or 0.1 FTE.

Highest-ranked leader dedicated FTE and premium compensation

Another pleasing trend is an increase in dedicated FTE for the highest-paid leader. Like any skill-set development, leadership requires the investment of deliberate practice, financial acumen, negotiation skills, and increased vulnerability. Time helps way more in developing these skill sets than money. SoHM trends show increase in dedicated FTE for the highest physician leader over the years and static premium compensation.

153365_Graph 3_web.jpg

At last, we can say median leadership is always better than “mean” leadership in skewed data. Pun apart, every group needs leadership, and SoHM offers a nice window to the trends in leadership amongst many practice groups. It is a valuable resource for every group.

Dr. Chadha is chief of the division of hospital medicine at the University of Kentucky Healthcare, Lexington. He actively leads efforts of recruiting, practice analysis, and operation of the group. He is finishing his first tenure in the Practice Analysis Committee. He is often found spending a lot more than required time with spreadsheets and graphs.

Reference

1. 2020 State of Hospital Medicine. www.hospitalmedicine.org/practice-management/shms-state-of-hospital-medicine/

The language of equality in America’s founding was never truly embraced, resulting in a painful legacy of slavery, racial injustice, and gender inequality inherited by all generations. However, for as long as America has fallen short of this unfulfilled promise, individuals have dedicated their lives to the tireless work of correcting injustice. Although the process has been painstakingly slow, our nation has incrementally inched toward the promised vision of equality, and these efforts continue today. With increased attention to social justice movements such as #MeToo and Black Lives Matter, our collective social consciousness may be finally waking up to the systemic injustices embedded into our fundamental institutions.

Delapenha_Andrew_MD_web.jpg

Medicine is not immune to these injustices. Persistent underrepresentation of women and minorities remains in medical school faculty and the broader physician workforce, and the same inequities exist in hospital medicine.^1-6 The report by the Association of American Medical Colleges (AAMC) on diversity in medicine highlights the impact widespread implicit and explicit bias has on creating exclusionary environments, exemplified by research demonstrating lower promotion rates in non-White faculty.^7-8 The report calls us, as physicians, to a broader mission: “Focusing solely on increasing compositional diversity along the academic continuum is insufficient. To effectively enact institutional change at academic medical centers ... leaders must focus their efforts on developing inclusive, equity-minded environments.”⁷

Kisuule_Flora_MD_2021_web.jpg

We have a clear moral imperative to correct these shortcomings for our profession and our patients. It is incumbent on our institutions and hospital medicine groups (HMGs) to embark on the necessary process of systemic institutional change to address inequality and justice within our field.

Martin_Shannon_K_IL_web.jpg

A road map for DEI and justice in hospital medicine

The policies and biases allowing these inequities to persist have existed for decades, and superficial efforts will not bring sufficient change. Our institutions require new building blocks from which the foundation of a wholly inclusive and equal system of practice can be constructed. Encouragingly, some institutions and HMGs have taken steps to modernize their practices. We offer examples and suggestions of concrete practices to begin this journey, organizing these efforts into three broad categories:

1. Recruitment and retention

2. Scholarship, mentorship, and sponsorship

3. Community engagement and partnership.

Barrett_Eileen_Alb_2021_web.jpg

Recruitment and retention

Improving equity and inclusion begins with recruitment. Search and hiring committees should be assembled intentionally, with gender balance, and ideally with diversity or equity experts invited to join. All members should receive unconscious bias training. For example, the University of Colorado utilizes a toolkit to ensure appropriate steps are followed in the recruitment process, including predetermined candidate selection criteria that are ranked in advance.

Job descriptions should be reviewed by a diversity expert, ensuring unbiased and ungendered language within written text. Advertisements should be wide-reaching, and the committee should consider asking applicants for a diversity statement. Interviews should include a variety of interviewers and interview types (e.g., 1:1, group, etc.). Letters of recommendation deserve special scrutiny; letters for women and minorities may be at risk of being shorter and less record focused, and may be subject to less professional respect, such as use of first names over honorifics or titles.

Once candidates are hired, institutions and HMGs should prioritize developing strategies to improve retention of a diverse workforce. This includes special attention to workplace culture, and thoughtfully striving for cultural intelligence within the group. Some examples may include developing affinity groups, such as underrepresented in medicine (UIM), women in medicine (WIM), or LGBTQ+ groups. Affinity groups provide a safe space for members and allies to support and uplift each other. Institutional and HMG leaders must educate themselves and their members on the importance of language (see table), and the more insidious forms of bias and discrimination that adversely affect workplace culture. Microinsults and microinvalidations, for example, can hurt and result in failure to recruit or turnover.

153409_DEI table_web.jpg

Scholarship, mentorship, and sponsorship

Women and minorities are known to be over-mentored and under-sponsored. Sponsorship is defined by Ayyala et al. as “active support by someone appropriately placed in the organization who has significant influence on decision making processes or structures and who is advocating for the career advancement of an individual and recommends them for leadership roles, awards, or high-profile speaking opportunities.”⁹ While the goal of mentorship is professional development, sponsorship emphasizes professional advancement. Deliberate steps to both mentor and then sponsor diverse hospitalists and future hospitalists (including trainees) are important to ensure equity.

More inclusive HMGs can be bolstered by prioritizing peer education on the professional imperative that we have a diverse workforce and equitable, just workplaces. Academic institutions may use existing structures such as grand rounds to provide education on these crucial topics, and all HMGs can host journal clubs and professional development sessions on leadership competencies that foster inclusion and equity. Sessions coordinated by women and minorities are also a form of justice, by helping overcome barriers to career advancement. Diverse faculty presenting in educational venues will result in content that is relevant to more audience members and will exemplify that leaders and experts are of all races, ethnicities, genders, ages, and abilities.

Groups should prioritize mentoring trainees and early-career hospitalists on scholarly projects that examine equity in opportunities of care, which signals that this science is valued as much as basic research. When used to demonstrate areas needing improvement, these projects can drive meaningful change. Even projects as straightforward as studying diversity in conference presenters, disparities in adherence to guidelines, or QI projects on how race is portrayed in the medical record can be powerful tools in advancing equity.

A key part of mentoring is training hospitalists and future hospitalists in how to be an upstander, as in how to intervene when a peer or patient is affected by bias, harassment, or discrimination. Receiving such training can prepare hospitalists for these nearly inevitable experiences and receiving training during usual work hours communicates that this is a valuable and necessary professional competency.
 

Community engagement and partnership

Institutions and HMGs should deliberately work to promote community engagement and partnership within their groups. Beyond promoting health equity, community engagement also fosters inclusivity by allowing community members to share their ideas and give recommendations to the institutions that serve them.

There is a growing body of literature that demonstrates how disadvantages by individual and neighborhood-level socioeconomic status (SES) contribute to disparities in specific disease conditions.^10-11 Strategies to narrow the gap in SES disadvantages may help reduce race-related health disparities. Institutions that engage the community and develop programs to promote health equity can do so through bidirectional exchange of knowledge and mutual benefit.

An institution-specific example is Medicine for the Greater Good at Johns Hopkins. The founders of this program wrote, “health is not synonymous with medicine. To truly care for our patients and their communities, health care professionals must understand how to deliver equitable health care that meets the needs of the diverse populations we care for. The mission of Medicine for the Greater Good is to promote health and wellness beyond the confines of the hospital through an interactive and engaging partnership with the community ...” Community engagement also provides an opportunity for growing the cultural intelligence of institutions and HMGs.
 

Tools for advancing comprehensive change – Repurposing PDSA cycles

Whether institutions and HMGs are at the beginning of their journey or further along in the work of reducing disparities, having a systematic approach for implementing and refining policies and procedures can cultivate more inclusive and equitable environments. Thankfully, hospitalists are already equipped with the fundamental tools needed to advance change across their institutions – QI processes in the form of Plan-Do-Study-Act (PDSA) cycles.

They allow a continuous cycle of successful incremental change based on direct evidence and experience. Any efforts to deconstruct systematic bias within our organizations must also be a continual process. Our female colleagues and colleagues of color need our institutions to engage unceasingly to bring about the equality they deserve. To that end, PDSA cycles are an apt tool to utilize in this work as they can naturally function in a never-ending process of improvement.

With PDSA as a model, we envision a cycle with steps that are intentionally purposed to fit the needs of equitable institutional change: Target-Engage-Assess-Modify. As highlighted (see graphic), these modifications ensure that stakeholders (i.e., those that unequal practices and policies affect the most) are engaged early and remain involved throughout the cycle.

153409 PDSA Cycle_web.jpg

Dr. Delapenha and Dr. Kisuule are based in the department of internal medicine, division of hospital medicine, at the Johns Hopkins University, Baltimore. Dr. Martin is based in the department of medicine, section of hospital medicine at the University of Chicago. Dr. Barrett is a hospitalist in the department of internal medicine, University of New Mexico, Albuquerque.

References

1. Diversity in Medicine: Facts and Figures 2019: Figure 19. Percentage of physicians by sex, 2018. AAMC website.

2. Diversity in Medicine: Facts and Figures 2019. Figure 16. Percentage of full-time U.S. medical school faculty by sex and race/ethnicity, 2018. AAMC website.

3. Diversity in Medicine: Facts and Figures 2019. Figure 15. Percentage of full-time U.S. medical school faculty by race/ethnicity, 2018. AAMC website.

4. Diversity in Medicine: Facts and Figures 2019. Figure 6. Percentage of acceptees to U.S. medical schools by race/ethnicity (alone), academic year 2018-2019. AAMC website.

5. Diversity in Medicine: Facts and Figures 2019 Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC website.

6. Herzke C et al. Gender issues in academic hospital medicine: A national survey of hospitalist leaders. J Gen Intern Med. 2020;35(6):1641-6.

7. Diversity in Medicine: Facts and Figures 2019. Fostering diversity and inclusion. AAMC website.

8. Diversity in Medicine: Facts and Figures 2019. Executive summary. AAMC website.

9. Ayyala MS et al. Mentorship is not enough: Exploring sponsorship and its role in career advancement in academic medicine. Acad Med. 2019;94(1):94-100.

10. Ejike OC et al. Contribution of individual and neighborhood factors to racial disparities in respiratory outcomes. Am J Respir Crit Care Med. 2021 Apr 15;203(8):987-97.

11. Galiatsatos P et al. The effect of community socioeconomic status on sepsis-attributable mortality. J Crit Care. 2018 Aug;46:129-33.

The language of equality in America’s founding was never truly embraced, resulting in a painful legacy of slavery, racial injustice, and gender inequality inherited by all generations. However, for as long as America has fallen short of this unfulfilled promise, individuals have dedicated their lives to the tireless work of correcting injustice. Although the process has been painstakingly slow, our nation has incrementally inched toward the promised vision of equality, and these efforts continue today. With increased attention to social justice movements such as #MeToo and Black Lives Matter, our collective social consciousness may be finally waking up to the systemic injustices embedded into our fundamental institutions.

Delapenha_Andrew_MD_web.jpg

Medicine is not immune to these injustices. Persistent underrepresentation of women and minorities remains in medical school faculty and the broader physician workforce, and the same inequities exist in hospital medicine.^1-6 The report by the Association of American Medical Colleges (AAMC) on diversity in medicine highlights the impact widespread implicit and explicit bias has on creating exclusionary environments, exemplified by research demonstrating lower promotion rates in non-White faculty.^7-8 The report calls us, as physicians, to a broader mission: “Focusing solely on increasing compositional diversity along the academic continuum is insufficient. To effectively enact institutional change at academic medical centers ... leaders must focus their efforts on developing inclusive, equity-minded environments.”⁷

Kisuule_Flora_MD_2021_web.jpg

We have a clear moral imperative to correct these shortcomings for our profession and our patients. It is incumbent on our institutions and hospital medicine groups (HMGs) to embark on the necessary process of systemic institutional change to address inequality and justice within our field.

Martin_Shannon_K_IL_web.jpg

A road map for DEI and justice in hospital medicine

The policies and biases allowing these inequities to persist have existed for decades, and superficial efforts will not bring sufficient change. Our institutions require new building blocks from which the foundation of a wholly inclusive and equal system of practice can be constructed. Encouragingly, some institutions and HMGs have taken steps to modernize their practices. We offer examples and suggestions of concrete practices to begin this journey, organizing these efforts into three broad categories:

1. Recruitment and retention

2. Scholarship, mentorship, and sponsorship

3. Community engagement and partnership.

Barrett_Eileen_Alb_2021_web.jpg

Recruitment and retention

Improving equity and inclusion begins with recruitment. Search and hiring committees should be assembled intentionally, with gender balance, and ideally with diversity or equity experts invited to join. All members should receive unconscious bias training. For example, the University of Colorado utilizes a toolkit to ensure appropriate steps are followed in the recruitment process, including predetermined candidate selection criteria that are ranked in advance.

Job descriptions should be reviewed by a diversity expert, ensuring unbiased and ungendered language within written text. Advertisements should be wide-reaching, and the committee should consider asking applicants for a diversity statement. Interviews should include a variety of interviewers and interview types (e.g., 1:1, group, etc.). Letters of recommendation deserve special scrutiny; letters for women and minorities may be at risk of being shorter and less record focused, and may be subject to less professional respect, such as use of first names over honorifics or titles.

Once candidates are hired, institutions and HMGs should prioritize developing strategies to improve retention of a diverse workforce. This includes special attention to workplace culture, and thoughtfully striving for cultural intelligence within the group. Some examples may include developing affinity groups, such as underrepresented in medicine (UIM), women in medicine (WIM), or LGBTQ+ groups. Affinity groups provide a safe space for members and allies to support and uplift each other. Institutional and HMG leaders must educate themselves and their members on the importance of language (see table), and the more insidious forms of bias and discrimination that adversely affect workplace culture. Microinsults and microinvalidations, for example, can hurt and result in failure to recruit or turnover.

153409_DEI table_web.jpg

Scholarship, mentorship, and sponsorship

Women and minorities are known to be over-mentored and under-sponsored. Sponsorship is defined by Ayyala et al. as “active support by someone appropriately placed in the organization who has significant influence on decision making processes or structures and who is advocating for the career advancement of an individual and recommends them for leadership roles, awards, or high-profile speaking opportunities.”⁹ While the goal of mentorship is professional development, sponsorship emphasizes professional advancement. Deliberate steps to both mentor and then sponsor diverse hospitalists and future hospitalists (including trainees) are important to ensure equity.

More inclusive HMGs can be bolstered by prioritizing peer education on the professional imperative that we have a diverse workforce and equitable, just workplaces. Academic institutions may use existing structures such as grand rounds to provide education on these crucial topics, and all HMGs can host journal clubs and professional development sessions on leadership competencies that foster inclusion and equity. Sessions coordinated by women and minorities are also a form of justice, by helping overcome barriers to career advancement. Diverse faculty presenting in educational venues will result in content that is relevant to more audience members and will exemplify that leaders and experts are of all races, ethnicities, genders, ages, and abilities.

Groups should prioritize mentoring trainees and early-career hospitalists on scholarly projects that examine equity in opportunities of care, which signals that this science is valued as much as basic research. When used to demonstrate areas needing improvement, these projects can drive meaningful change. Even projects as straightforward as studying diversity in conference presenters, disparities in adherence to guidelines, or QI projects on how race is portrayed in the medical record can be powerful tools in advancing equity.

A key part of mentoring is training hospitalists and future hospitalists in how to be an upstander, as in how to intervene when a peer or patient is affected by bias, harassment, or discrimination. Receiving such training can prepare hospitalists for these nearly inevitable experiences and receiving training during usual work hours communicates that this is a valuable and necessary professional competency.
 

Community engagement and partnership

Institutions and HMGs should deliberately work to promote community engagement and partnership within their groups. Beyond promoting health equity, community engagement also fosters inclusivity by allowing community members to share their ideas and give recommendations to the institutions that serve them.

There is a growing body of literature that demonstrates how disadvantages by individual and neighborhood-level socioeconomic status (SES) contribute to disparities in specific disease conditions.^10-11 Strategies to narrow the gap in SES disadvantages may help reduce race-related health disparities. Institutions that engage the community and develop programs to promote health equity can do so through bidirectional exchange of knowledge and mutual benefit.

An institution-specific example is Medicine for the Greater Good at Johns Hopkins. The founders of this program wrote, “health is not synonymous with medicine. To truly care for our patients and their communities, health care professionals must understand how to deliver equitable health care that meets the needs of the diverse populations we care for. The mission of Medicine for the Greater Good is to promote health and wellness beyond the confines of the hospital through an interactive and engaging partnership with the community ...” Community engagement also provides an opportunity for growing the cultural intelligence of institutions and HMGs.
 

Tools for advancing comprehensive change – Repurposing PDSA cycles

Whether institutions and HMGs are at the beginning of their journey or further along in the work of reducing disparities, having a systematic approach for implementing and refining policies and procedures can cultivate more inclusive and equitable environments. Thankfully, hospitalists are already equipped with the fundamental tools needed to advance change across their institutions – QI processes in the form of Plan-Do-Study-Act (PDSA) cycles.

They allow a continuous cycle of successful incremental change based on direct evidence and experience. Any efforts to deconstruct systematic bias within our organizations must also be a continual process. Our female colleagues and colleagues of color need our institutions to engage unceasingly to bring about the equality they deserve. To that end, PDSA cycles are an apt tool to utilize in this work as they can naturally function in a never-ending process of improvement.

With PDSA as a model, we envision a cycle with steps that are intentionally purposed to fit the needs of equitable institutional change: Target-Engage-Assess-Modify. As highlighted (see graphic), these modifications ensure that stakeholders (i.e., those that unequal practices and policies affect the most) are engaged early and remain involved throughout the cycle.

153409 PDSA Cycle_web.jpg

Dr. Delapenha and Dr. Kisuule are based in the department of internal medicine, division of hospital medicine, at the Johns Hopkins University, Baltimore. Dr. Martin is based in the department of medicine, section of hospital medicine at the University of Chicago. Dr. Barrett is a hospitalist in the department of internal medicine, University of New Mexico, Albuquerque.

References

1. Diversity in Medicine: Facts and Figures 2019: Figure 19. Percentage of physicians by sex, 2018. AAMC website.

2. Diversity in Medicine: Facts and Figures 2019. Figure 16. Percentage of full-time U.S. medical school faculty by sex and race/ethnicity, 2018. AAMC website.

3. Diversity in Medicine: Facts and Figures 2019. Figure 15. Percentage of full-time U.S. medical school faculty by race/ethnicity, 2018. AAMC website.

4. Diversity in Medicine: Facts and Figures 2019. Figure 6. Percentage of acceptees to U.S. medical schools by race/ethnicity (alone), academic year 2018-2019. AAMC website.

5. Diversity in Medicine: Facts and Figures 2019 Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC website.

6. Herzke C et al. Gender issues in academic hospital medicine: A national survey of hospitalist leaders. J Gen Intern Med. 2020;35(6):1641-6.

7. Diversity in Medicine: Facts and Figures 2019. Fostering diversity and inclusion. AAMC website.

8. Diversity in Medicine: Facts and Figures 2019. Executive summary. AAMC website.

9. Ayyala MS et al. Mentorship is not enough: Exploring sponsorship and its role in career advancement in academic medicine. Acad Med. 2019;94(1):94-100.

10. Ejike OC et al. Contribution of individual and neighborhood factors to racial disparities in respiratory outcomes. Am J Respir Crit Care Med. 2021 Apr 15;203(8):987-97.

11. Galiatsatos P et al. The effect of community socioeconomic status on sepsis-attributable mortality. J Crit Care. 2018 Aug;46:129-33.

The language of equality in America’s founding was never truly embraced, resulting in a painful legacy of slavery, racial injustice, and gender inequality inherited by all generations. However, for as long as America has fallen short of this unfulfilled promise, individuals have dedicated their lives to the tireless work of correcting injustice. Although the process has been painstakingly slow, our nation has incrementally inched toward the promised vision of equality, and these efforts continue today. With increased attention to social justice movements such as #MeToo and Black Lives Matter, our collective social consciousness may be finally waking up to the systemic injustices embedded into our fundamental institutions.

Delapenha_Andrew_MD_web.jpg

Medicine is not immune to these injustices. Persistent underrepresentation of women and minorities remains in medical school faculty and the broader physician workforce, and the same inequities exist in hospital medicine.^1-6 The report by the Association of American Medical Colleges (AAMC) on diversity in medicine highlights the impact widespread implicit and explicit bias has on creating exclusionary environments, exemplified by research demonstrating lower promotion rates in non-White faculty.^7-8 The report calls us, as physicians, to a broader mission: “Focusing solely on increasing compositional diversity along the academic continuum is insufficient. To effectively enact institutional change at academic medical centers ... leaders must focus their efforts on developing inclusive, equity-minded environments.”⁷

Kisuule_Flora_MD_2021_web.jpg

We have a clear moral imperative to correct these shortcomings for our profession and our patients. It is incumbent on our institutions and hospital medicine groups (HMGs) to embark on the necessary process of systemic institutional change to address inequality and justice within our field.

Martin_Shannon_K_IL_web.jpg

A road map for DEI and justice in hospital medicine

The policies and biases allowing these inequities to persist have existed for decades, and superficial efforts will not bring sufficient change. Our institutions require new building blocks from which the foundation of a wholly inclusive and equal system of practice can be constructed. Encouragingly, some institutions and HMGs have taken steps to modernize their practices. We offer examples and suggestions of concrete practices to begin this journey, organizing these efforts into three broad categories:

1. Recruitment and retention

2. Scholarship, mentorship, and sponsorship

3. Community engagement and partnership.

Barrett_Eileen_Alb_2021_web.jpg

Recruitment and retention

Improving equity and inclusion begins with recruitment. Search and hiring committees should be assembled intentionally, with gender balance, and ideally with diversity or equity experts invited to join. All members should receive unconscious bias training. For example, the University of Colorado utilizes a toolkit to ensure appropriate steps are followed in the recruitment process, including predetermined candidate selection criteria that are ranked in advance.

Job descriptions should be reviewed by a diversity expert, ensuring unbiased and ungendered language within written text. Advertisements should be wide-reaching, and the committee should consider asking applicants for a diversity statement. Interviews should include a variety of interviewers and interview types (e.g., 1:1, group, etc.). Letters of recommendation deserve special scrutiny; letters for women and minorities may be at risk of being shorter and less record focused, and may be subject to less professional respect, such as use of first names over honorifics or titles.

Once candidates are hired, institutions and HMGs should prioritize developing strategies to improve retention of a diverse workforce. This includes special attention to workplace culture, and thoughtfully striving for cultural intelligence within the group. Some examples may include developing affinity groups, such as underrepresented in medicine (UIM), women in medicine (WIM), or LGBTQ+ groups. Affinity groups provide a safe space for members and allies to support and uplift each other. Institutional and HMG leaders must educate themselves and their members on the importance of language (see table), and the more insidious forms of bias and discrimination that adversely affect workplace culture. Microinsults and microinvalidations, for example, can hurt and result in failure to recruit or turnover.

153409_DEI table_web.jpg

Scholarship, mentorship, and sponsorship

Women and minorities are known to be over-mentored and under-sponsored. Sponsorship is defined by Ayyala et al. as “active support by someone appropriately placed in the organization who has significant influence on decision making processes or structures and who is advocating for the career advancement of an individual and recommends them for leadership roles, awards, or high-profile speaking opportunities.”⁹ While the goal of mentorship is professional development, sponsorship emphasizes professional advancement. Deliberate steps to both mentor and then sponsor diverse hospitalists and future hospitalists (including trainees) are important to ensure equity.

More inclusive HMGs can be bolstered by prioritizing peer education on the professional imperative that we have a diverse workforce and equitable, just workplaces. Academic institutions may use existing structures such as grand rounds to provide education on these crucial topics, and all HMGs can host journal clubs and professional development sessions on leadership competencies that foster inclusion and equity. Sessions coordinated by women and minorities are also a form of justice, by helping overcome barriers to career advancement. Diverse faculty presenting in educational venues will result in content that is relevant to more audience members and will exemplify that leaders and experts are of all races, ethnicities, genders, ages, and abilities.

Groups should prioritize mentoring trainees and early-career hospitalists on scholarly projects that examine equity in opportunities of care, which signals that this science is valued as much as basic research. When used to demonstrate areas needing improvement, these projects can drive meaningful change. Even projects as straightforward as studying diversity in conference presenters, disparities in adherence to guidelines, or QI projects on how race is portrayed in the medical record can be powerful tools in advancing equity.

A key part of mentoring is training hospitalists and future hospitalists in how to be an upstander, as in how to intervene when a peer or patient is affected by bias, harassment, or discrimination. Receiving such training can prepare hospitalists for these nearly inevitable experiences and receiving training during usual work hours communicates that this is a valuable and necessary professional competency.
 

Community engagement and partnership

Institutions and HMGs should deliberately work to promote community engagement and partnership within their groups. Beyond promoting health equity, community engagement also fosters inclusivity by allowing community members to share their ideas and give recommendations to the institutions that serve them.

There is a growing body of literature that demonstrates how disadvantages by individual and neighborhood-level socioeconomic status (SES) contribute to disparities in specific disease conditions.^10-11 Strategies to narrow the gap in SES disadvantages may help reduce race-related health disparities. Institutions that engage the community and develop programs to promote health equity can do so through bidirectional exchange of knowledge and mutual benefit.

An institution-specific example is Medicine for the Greater Good at Johns Hopkins. The founders of this program wrote, “health is not synonymous with medicine. To truly care for our patients and their communities, health care professionals must understand how to deliver equitable health care that meets the needs of the diverse populations we care for. The mission of Medicine for the Greater Good is to promote health and wellness beyond the confines of the hospital through an interactive and engaging partnership with the community ...” Community engagement also provides an opportunity for growing the cultural intelligence of institutions and HMGs.
 

Tools for advancing comprehensive change – Repurposing PDSA cycles

Whether institutions and HMGs are at the beginning of their journey or further along in the work of reducing disparities, having a systematic approach for implementing and refining policies and procedures can cultivate more inclusive and equitable environments. Thankfully, hospitalists are already equipped with the fundamental tools needed to advance change across their institutions – QI processes in the form of Plan-Do-Study-Act (PDSA) cycles.

They allow a continuous cycle of successful incremental change based on direct evidence and experience. Any efforts to deconstruct systematic bias within our organizations must also be a continual process. Our female colleagues and colleagues of color need our institutions to engage unceasingly to bring about the equality they deserve. To that end, PDSA cycles are an apt tool to utilize in this work as they can naturally function in a never-ending process of improvement.

With PDSA as a model, we envision a cycle with steps that are intentionally purposed to fit the needs of equitable institutional change: Target-Engage-Assess-Modify. As highlighted (see graphic), these modifications ensure that stakeholders (i.e., those that unequal practices and policies affect the most) are engaged early and remain involved throughout the cycle.

153409 PDSA Cycle_web.jpg

Dr. Delapenha and Dr. Kisuule are based in the department of internal medicine, division of hospital medicine, at the Johns Hopkins University, Baltimore. Dr. Martin is based in the department of medicine, section of hospital medicine at the University of Chicago. Dr. Barrett is a hospitalist in the department of internal medicine, University of New Mexico, Albuquerque.

References

1. Diversity in Medicine: Facts and Figures 2019: Figure 19. Percentage of physicians by sex, 2018. AAMC website.

2. Diversity in Medicine: Facts and Figures 2019. Figure 16. Percentage of full-time U.S. medical school faculty by sex and race/ethnicity, 2018. AAMC website.

3. Diversity in Medicine: Facts and Figures 2019. Figure 15. Percentage of full-time U.S. medical school faculty by race/ethnicity, 2018. AAMC website.

4. Diversity in Medicine: Facts and Figures 2019. Figure 6. Percentage of acceptees to U.S. medical schools by race/ethnicity (alone), academic year 2018-2019. AAMC website.

5. Diversity in Medicine: Facts and Figures 2019 Figure 18. Percentage of all active physicians by race/ethnicity, 2018. AAMC website.

6. Herzke C et al. Gender issues in academic hospital medicine: A national survey of hospitalist leaders. J Gen Intern Med. 2020;35(6):1641-6.

7. Diversity in Medicine: Facts and Figures 2019. Fostering diversity and inclusion. AAMC website.

8. Diversity in Medicine: Facts and Figures 2019. Executive summary. AAMC website.

9. Ayyala MS et al. Mentorship is not enough: Exploring sponsorship and its role in career advancement in academic medicine. Acad Med. 2019;94(1):94-100.

10. Ejike OC et al. Contribution of individual and neighborhood factors to racial disparities in respiratory outcomes. Am J Respir Crit Care Med. 2021 Apr 15;203(8):987-97.

11. Galiatsatos P et al. The effect of community socioeconomic status on sepsis-attributable mortality. J Crit Care. 2018 Aug;46:129-33.

The Society of Hospital Medicine’s annual Chapter Excellence Exemplary Awards have additional meaning this year, in the wake of the persistent challenges faced by the medical profession as a result of the COVID-19 pandemic.

153104_photo_web.jpg

“The Chapter Excellence Award program is an annual rewards program to recognize outstanding work conducted by chapters to carry out the SHM mission locally,” Lisa Kroll, associate director of membership at SHM, said in an interview.

The Chapter Excellence Award program is composed of Status Awards (Platinum, Gold, Silver, and Bronze) and Exemplary Awards. “Chapters that receive these awards have demonstrated growth, sustenance, and innovation within their chapter activities,” Ms. Kroll said.

For 2020, the Houston Chapter received the Outstanding Chapter of the Year Award, the Hampton Roads (Va.) Chapter received the Resiliency Award, and Amith Skandhan, MD, SFHM, of the Wiregrass Chapter in Alabama, received the Most Engaged Chapter Leader Award.

“SHM members are assigned to a chapter based on their geographical location and are provided opportunities for education and networking through in-person and virtual events, volunteering in a chapter leadership position, and connecting with local hospitalists through the chapter’s community in HMX, SHM’s online engagement platform,” Ms. Kroll said.

The Houston Chapter received the Outstanding Chapter of the Year Award because it “exemplified high performance during 2020,” Ms. Kroll said. “During a particularly challenging year for everyone, the chapter was able to rethink how they could make the largest impact for members and expand their audience with the use of virtual meetings, provide incentives for participants, and expand their leadership team.”

“The Houston Chapter has been successful in establishing a Houston-wide Resident Interest Group to better involve and provide SHM resources to the residents within the four local internal medicine residency programs who are interested in hospital medicine,” Ms. Kroll said. “Additionally, the chapter created its first curriculum to assist residents in knowing more about hospital medicine and how to approach the job search. The Houston Chapter has provided sources of support, both emotionally and professionally, and incorporated comedians and musicians into their web meetings to provide a much-needed break from medical content.”

The Resiliency Award is a new SHM award category that goes to one chapter that has gone “above and beyond” to showcase their ability to withstand and rise above hardships, as well as to successfully adapt and position the chapter for long term sustainability and success, according to Ms. Kroll. “The Hampton Roads Chapter received this award for the 2020 year. Some of the chapter’s accomplishments included initiating a provider well-being series.”

Ms. Kroll noted that the Hampton Roads Chapter thrived by trying new approaches and ideas to bring hospitalists together across a wide region, such as by utilizing the virtual format to provide more specialized outreach to providers and recognize hospitalists’ contributions to the broader community.

The Most Engaged Chapter Leader Award was given to Alabama-based hospitalist Dr. Skandhan, who “has demonstrated how he goes above and beyond to grow and sustain the Wiregrass Chapter of SHM and continues to carry out the SHM mission,” Ms. Kroll said.

Dr. Skandhan’s accomplishments in 2020 include inviting four Alabama state representatives and three Alabama state senators to participate in a case discussion with Wiregrass Chapter leaders; creating and moderating a weekly check-in platform for the Alabama state hospital-medicine program directors’ forum through the Wiregrass Chapter – a project that enabled him to encourage the sharing of information between hospital medicine program directors; and working with the other Wiregrass Chapter leaders to launch a poster competition on Twitter with more than 80 posters presented. 
 

Hampton Roads Chapter embraces virtual connections

“I believe chapters are one of the best answers to the question: ‘What’s the value of joining SHM?’” Thomas Miller, MD, FHM, leader of the Hampton Roads Chapter, said in an interview.

“Sharing ideas and experiences with other hospitalist teams in a region, coordinating efforts to improve care, and the personal connection with others in your field are very important for hospitalists,” he emphasized. “Chapters are uniquely positioned to do just that. Recognizing individual chapters is a great way to highlight these benefits and to promote new ideas – which other chapters can incorporate into their future plans.”

The Hampton Roads Chapter demonstrated its resilience in many ways during the challenging year of 2020, Dr. Miller said.

“We love our in-person meetings,” he emphasized. “When 2020 took that away from us, we tried to make the most of the situation by embracing the reduced overhead of the virtual format to offer more specialized outreach programs, such as ‘Cultural Context Matters: How Race and Culture Impact Health Outcomes’ and ‘Critical Care: Impact of Immigration Policy on U.S. Healthcare.’ ” The critical care and immigration program “was a great outreach to our many international physicians who have faced special struggles during COVID; it not only highlighted these issues to other hospitalists, but to the broader community, since it was a joint meeting with our local World Affairs Council,” he added.

Dr. Miller also was impressed with the resilience of other chapter members, “such as our vice president, Dr. Gwen Williams, who put together a provider well-being series, ‘Hospitalist Well Being & Support in Times of Crisis.’ ” He expressed further appreciation for the multiple chapter members who supported the chapter’s virtual resident abstract/poster competition.

“Despite the limitations imposed by 2020, we have used unique approaches that have held together a strong core group while broadening outreach to new providers in our region through programs like those described,” said Dr. Miller. “At the same time, we have promoted hospital medicine to the broader community through a joint program, increased social media presence, and achieved cover articles in Hampton Roads Physician about hospital medicine and a ‘Heroes of COVID’ story featuring chapter members. We also continued our effort to add value by providing ready access to the newly state-mandated CME with ‘Opiate Prescribing in the 21st Century.’

“In a time when even family and close friends struggled to maintain connection, we found ways to offer that to our hospitalist teams, at the same time experimenting with new tools that we can put to use long after COVID is gone,” Dr. Miller added.
 

Houston Chapter supports residents, provides levity

“As a medical community, we hope that the award recognition brings more attention to the issues for which our chapter advocates,” Jeffrey W. Chen, MD, of the Houston Chapter and a hospitalist at Memorial Hermann Hospital Texas Medical Center, said in an interview.

Chen_Jeffrey_W_TEX_web.jpg

“We hope that it encourages more residents to pursue hospital medicine, and encourages early career hospitalists to get plugged in to the incredible opportunities our chapter offers,” he said. “We are so incredibly honored that the Society of Hospital Medicine has recognized the decade of work that has gone on to get to where we are now. We started with one officer, and we have worked so hard to grow and expand over the years so we can help support our fellow hospitalists across the city and state. 

“We are excited about what our chapter has been able to achieve,” said Dr. Chen. “We united the four internal medicine residencies around Houston and created a Houston-wide Hospitalist Interest Group to support residents, providing them the resources they need to be successful in pursuing a career in hospital medicine. We also are proud of the support we provided this year to our early career hospitalists, helping them navigate the transitions and stay up to date in topics relevant to hospital medicine. We held our biggest abstract competition yet, and held a virtual research showcase to celebrate the incredible clinical advancements still happening during the midst of the pandemic.

“It was certainly a tough and challenging year for all chapters, but despite us not being able to hold the in-person dinners that our members love so much, we were proud that we were able to have such a big year,” said Dr. Chen. “We were thankful for the physicians who led our COVID-19 talks, which provided an opportunity for hospitalists across Houston to collaborate and share ideas on which treatments and therapies were working well for their patients. During such a difficult year, we also hosted our first wellness events, including a comedian and band to bring some light during tough times.”
 

Strong leader propels team efforts

“The Chapter Exemplary Awards Program is important because it encourages higher performance while increasing membership engagement and retaining talent,” said Dr. Skandhan, of Southeast Health Medical Center in Dothan, Ala., and winner of the Most Engaged Chapter Leader award. “Being recognized as the most engaged chapter leader is an honor, especially given the national and international presence of SHM.

Skandhan_Amith_AL_web.jpg

“Success is achieved through the help and support of your peers and mentors, and I am fortunate to have found them through this organization,” said Dr. Skandhan. “This award brings attention to the fantastic work done by the engaged membership and leadership of the Wiregrass Chapter. This recognition makes me proud to be part of a team that prides itself on improving the quality health and wellbeing of the patients, providers, and public through innovation and collaboration; this is a testament to their work.”

Dr. Skandhan’s activities as a chapter leader included visiting health care facilities in the rural Southeastern United States. “I slowly began to learn how small towns and their economies tied into a health system, how invested the health care providers were towards their communities, and how health care disparities existed between the rural and urban populations,” he explained. “When the COVID-19 pandemic hit, I worried about these hospitals and their providers. COVID-19 was a new disease with limited understanding of the virus, treatment options, and prevention protocols.” To help smaller hospitals, the Wiregrass Chapter created a weekly check-in for hospital medicine program directors in the state of Alabama, he said.

“We would start the meeting with each participant reporting the total number of cases, ventilator usage, COVID-19 deaths, and one policy change they did that week to address a pressing issue,” Dr. Skandhan said. “Over time the meetings helped address common challenges and were a source of physician well-being.”

In addition, Dr. Skandhan and his chapter colleagues were concerned that academics were taking a back seat to the pandemic, so they rose to the challenge by designing a Twitter-based poster competition using judges from across the country. “This project was led by one of our chapter leaders, Dr. Arash Velayati of Southeast Health Medical Center,” said Dr. Skandhan. The contest included 82 posters, and the participants were able to showcase their work to a large, virtual audience.

Dr. Skandhan and colleagues also decided to partner with religious leaders in their community to help combat the spread of misinformation about COVID-19. “We teamed with the Southern Alabama Baptist Association and Interfaith Council to educate these religious leaders on the issues around COVID-19,” and addressed topics including masking and social distancing, and provided resources for religious leaders to tackle misinformation in their communities, he said.

“As chapter leaders, we need to learn to think outside the box,” Dr. Skandhan emphasized. “We can affect health care quality when we strive to solve more significant problems by bringing people together, brainstorming, and collaborating. SHM and chapter-level engagement provide us with that opportunity.“Hospitalists are often affected by the downstream effects of limited preventive care addressing chronic illnesses. Therefore, we have to strive to see the bigger picture. As we make changes at our local institutions and chapter levels, we will start seeing the improvement we hope to see in the care of our patients and our communities.”

The Society of Hospital Medicine’s annual Chapter Excellence Exemplary Awards have additional meaning this year, in the wake of the persistent challenges faced by the medical profession as a result of the COVID-19 pandemic.

153104_photo_web.jpg

“The Chapter Excellence Award program is an annual rewards program to recognize outstanding work conducted by chapters to carry out the SHM mission locally,” Lisa Kroll, associate director of membership at SHM, said in an interview.

The Chapter Excellence Award program is composed of Status Awards (Platinum, Gold, Silver, and Bronze) and Exemplary Awards. “Chapters that receive these awards have demonstrated growth, sustenance, and innovation within their chapter activities,” Ms. Kroll said.

For 2020, the Houston Chapter received the Outstanding Chapter of the Year Award, the Hampton Roads (Va.) Chapter received the Resiliency Award, and Amith Skandhan, MD, SFHM, of the Wiregrass Chapter in Alabama, received the Most Engaged Chapter Leader Award.

“SHM members are assigned to a chapter based on their geographical location and are provided opportunities for education and networking through in-person and virtual events, volunteering in a chapter leadership position, and connecting with local hospitalists through the chapter’s community in HMX, SHM’s online engagement platform,” Ms. Kroll said.

The Houston Chapter received the Outstanding Chapter of the Year Award because it “exemplified high performance during 2020,” Ms. Kroll said. “During a particularly challenging year for everyone, the chapter was able to rethink how they could make the largest impact for members and expand their audience with the use of virtual meetings, provide incentives for participants, and expand their leadership team.”

“The Houston Chapter has been successful in establishing a Houston-wide Resident Interest Group to better involve and provide SHM resources to the residents within the four local internal medicine residency programs who are interested in hospital medicine,” Ms. Kroll said. “Additionally, the chapter created its first curriculum to assist residents in knowing more about hospital medicine and how to approach the job search. The Houston Chapter has provided sources of support, both emotionally and professionally, and incorporated comedians and musicians into their web meetings to provide a much-needed break from medical content.”

The Resiliency Award is a new SHM award category that goes to one chapter that has gone “above and beyond” to showcase their ability to withstand and rise above hardships, as well as to successfully adapt and position the chapter for long term sustainability and success, according to Ms. Kroll. “The Hampton Roads Chapter received this award for the 2020 year. Some of the chapter’s accomplishments included initiating a provider well-being series.”

Ms. Kroll noted that the Hampton Roads Chapter thrived by trying new approaches and ideas to bring hospitalists together across a wide region, such as by utilizing the virtual format to provide more specialized outreach to providers and recognize hospitalists’ contributions to the broader community.

The Most Engaged Chapter Leader Award was given to Alabama-based hospitalist Dr. Skandhan, who “has demonstrated how he goes above and beyond to grow and sustain the Wiregrass Chapter of SHM and continues to carry out the SHM mission,” Ms. Kroll said.

Dr. Skandhan’s accomplishments in 2020 include inviting four Alabama state representatives and three Alabama state senators to participate in a case discussion with Wiregrass Chapter leaders; creating and moderating a weekly check-in platform for the Alabama state hospital-medicine program directors’ forum through the Wiregrass Chapter – a project that enabled him to encourage the sharing of information between hospital medicine program directors; and working with the other Wiregrass Chapter leaders to launch a poster competition on Twitter with more than 80 posters presented. 
 

Hampton Roads Chapter embraces virtual connections

“I believe chapters are one of the best answers to the question: ‘What’s the value of joining SHM?’” Thomas Miller, MD, FHM, leader of the Hampton Roads Chapter, said in an interview.

“Sharing ideas and experiences with other hospitalist teams in a region, coordinating efforts to improve care, and the personal connection with others in your field are very important for hospitalists,” he emphasized. “Chapters are uniquely positioned to do just that. Recognizing individual chapters is a great way to highlight these benefits and to promote new ideas – which other chapters can incorporate into their future plans.”

The Hampton Roads Chapter demonstrated its resilience in many ways during the challenging year of 2020, Dr. Miller said.

“We love our in-person meetings,” he emphasized. “When 2020 took that away from us, we tried to make the most of the situation by embracing the reduced overhead of the virtual format to offer more specialized outreach programs, such as ‘Cultural Context Matters: How Race and Culture Impact Health Outcomes’ and ‘Critical Care: Impact of Immigration Policy on U.S. Healthcare.’ ” The critical care and immigration program “was a great outreach to our many international physicians who have faced special struggles during COVID; it not only highlighted these issues to other hospitalists, but to the broader community, since it was a joint meeting with our local World Affairs Council,” he added.

Dr. Miller also was impressed with the resilience of other chapter members, “such as our vice president, Dr. Gwen Williams, who put together a provider well-being series, ‘Hospitalist Well Being & Support in Times of Crisis.’ ” He expressed further appreciation for the multiple chapter members who supported the chapter’s virtual resident abstract/poster competition.

“Despite the limitations imposed by 2020, we have used unique approaches that have held together a strong core group while broadening outreach to new providers in our region through programs like those described,” said Dr. Miller. “At the same time, we have promoted hospital medicine to the broader community through a joint program, increased social media presence, and achieved cover articles in Hampton Roads Physician about hospital medicine and a ‘Heroes of COVID’ story featuring chapter members. We also continued our effort to add value by providing ready access to the newly state-mandated CME with ‘Opiate Prescribing in the 21st Century.’

“In a time when even family and close friends struggled to maintain connection, we found ways to offer that to our hospitalist teams, at the same time experimenting with new tools that we can put to use long after COVID is gone,” Dr. Miller added.
 

Houston Chapter supports residents, provides levity

“As a medical community, we hope that the award recognition brings more attention to the issues for which our chapter advocates,” Jeffrey W. Chen, MD, of the Houston Chapter and a hospitalist at Memorial Hermann Hospital Texas Medical Center, said in an interview.

Chen_Jeffrey_W_TEX_web.jpg

“We hope that it encourages more residents to pursue hospital medicine, and encourages early career hospitalists to get plugged in to the incredible opportunities our chapter offers,” he said. “We are so incredibly honored that the Society of Hospital Medicine has recognized the decade of work that has gone on to get to where we are now. We started with one officer, and we have worked so hard to grow and expand over the years so we can help support our fellow hospitalists across the city and state. 

“We are excited about what our chapter has been able to achieve,” said Dr. Chen. “We united the four internal medicine residencies around Houston and created a Houston-wide Hospitalist Interest Group to support residents, providing them the resources they need to be successful in pursuing a career in hospital medicine. We also are proud of the support we provided this year to our early career hospitalists, helping them navigate the transitions and stay up to date in topics relevant to hospital medicine. We held our biggest abstract competition yet, and held a virtual research showcase to celebrate the incredible clinical advancements still happening during the midst of the pandemic.

“It was certainly a tough and challenging year for all chapters, but despite us not being able to hold the in-person dinners that our members love so much, we were proud that we were able to have such a big year,” said Dr. Chen. “We were thankful for the physicians who led our COVID-19 talks, which provided an opportunity for hospitalists across Houston to collaborate and share ideas on which treatments and therapies were working well for their patients. During such a difficult year, we also hosted our first wellness events, including a comedian and band to bring some light during tough times.”
 

Strong leader propels team efforts

“The Chapter Exemplary Awards Program is important because it encourages higher performance while increasing membership engagement and retaining talent,” said Dr. Skandhan, of Southeast Health Medical Center in Dothan, Ala., and winner of the Most Engaged Chapter Leader award. “Being recognized as the most engaged chapter leader is an honor, especially given the national and international presence of SHM.

Skandhan_Amith_AL_web.jpg

“Success is achieved through the help and support of your peers and mentors, and I am fortunate to have found them through this organization,” said Dr. Skandhan. “This award brings attention to the fantastic work done by the engaged membership and leadership of the Wiregrass Chapter. This recognition makes me proud to be part of a team that prides itself on improving the quality health and wellbeing of the patients, providers, and public through innovation and collaboration; this is a testament to their work.”

Dr. Skandhan’s activities as a chapter leader included visiting health care facilities in the rural Southeastern United States. “I slowly began to learn how small towns and their economies tied into a health system, how invested the health care providers were towards their communities, and how health care disparities existed between the rural and urban populations,” he explained. “When the COVID-19 pandemic hit, I worried about these hospitals and their providers. COVID-19 was a new disease with limited understanding of the virus, treatment options, and prevention protocols.” To help smaller hospitals, the Wiregrass Chapter created a weekly check-in for hospital medicine program directors in the state of Alabama, he said.

“We would start the meeting with each participant reporting the total number of cases, ventilator usage, COVID-19 deaths, and one policy change they did that week to address a pressing issue,” Dr. Skandhan said. “Over time the meetings helped address common challenges and were a source of physician well-being.”

In addition, Dr. Skandhan and his chapter colleagues were concerned that academics were taking a back seat to the pandemic, so they rose to the challenge by designing a Twitter-based poster competition using judges from across the country. “This project was led by one of our chapter leaders, Dr. Arash Velayati of Southeast Health Medical Center,” said Dr. Skandhan. The contest included 82 posters, and the participants were able to showcase their work to a large, virtual audience.

Dr. Skandhan and colleagues also decided to partner with religious leaders in their community to help combat the spread of misinformation about COVID-19. “We teamed with the Southern Alabama Baptist Association and Interfaith Council to educate these religious leaders on the issues around COVID-19,” and addressed topics including masking and social distancing, and provided resources for religious leaders to tackle misinformation in their communities, he said.

“As chapter leaders, we need to learn to think outside the box,” Dr. Skandhan emphasized. “We can affect health care quality when we strive to solve more significant problems by bringing people together, brainstorming, and collaborating. SHM and chapter-level engagement provide us with that opportunity.“Hospitalists are often affected by the downstream effects of limited preventive care addressing chronic illnesses. Therefore, we have to strive to see the bigger picture. As we make changes at our local institutions and chapter levels, we will start seeing the improvement we hope to see in the care of our patients and our communities.”

The Society of Hospital Medicine’s annual Chapter Excellence Exemplary Awards have additional meaning this year, in the wake of the persistent challenges faced by the medical profession as a result of the COVID-19 pandemic.

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“The Chapter Excellence Award program is an annual rewards program to recognize outstanding work conducted by chapters to carry out the SHM mission locally,” Lisa Kroll, associate director of membership at SHM, said in an interview.

The Chapter Excellence Award program is composed of Status Awards (Platinum, Gold, Silver, and Bronze) and Exemplary Awards. “Chapters that receive these awards have demonstrated growth, sustenance, and innovation within their chapter activities,” Ms. Kroll said.

For 2020, the Houston Chapter received the Outstanding Chapter of the Year Award, the Hampton Roads (Va.) Chapter received the Resiliency Award, and Amith Skandhan, MD, SFHM, of the Wiregrass Chapter in Alabama, received the Most Engaged Chapter Leader Award.

“SHM members are assigned to a chapter based on their geographical location and are provided opportunities for education and networking through in-person and virtual events, volunteering in a chapter leadership position, and connecting with local hospitalists through the chapter’s community in HMX, SHM’s online engagement platform,” Ms. Kroll said.

The Houston Chapter received the Outstanding Chapter of the Year Award because it “exemplified high performance during 2020,” Ms. Kroll said. “During a particularly challenging year for everyone, the chapter was able to rethink how they could make the largest impact for members and expand their audience with the use of virtual meetings, provide incentives for participants, and expand their leadership team.”

“The Houston Chapter has been successful in establishing a Houston-wide Resident Interest Group to better involve and provide SHM resources to the residents within the four local internal medicine residency programs who are interested in hospital medicine,” Ms. Kroll said. “Additionally, the chapter created its first curriculum to assist residents in knowing more about hospital medicine and how to approach the job search. The Houston Chapter has provided sources of support, both emotionally and professionally, and incorporated comedians and musicians into their web meetings to provide a much-needed break from medical content.”

The Resiliency Award is a new SHM award category that goes to one chapter that has gone “above and beyond” to showcase their ability to withstand and rise above hardships, as well as to successfully adapt and position the chapter for long term sustainability and success, according to Ms. Kroll. “The Hampton Roads Chapter received this award for the 2020 year. Some of the chapter’s accomplishments included initiating a provider well-being series.”

Ms. Kroll noted that the Hampton Roads Chapter thrived by trying new approaches and ideas to bring hospitalists together across a wide region, such as by utilizing the virtual format to provide more specialized outreach to providers and recognize hospitalists’ contributions to the broader community.

The Most Engaged Chapter Leader Award was given to Alabama-based hospitalist Dr. Skandhan, who “has demonstrated how he goes above and beyond to grow and sustain the Wiregrass Chapter of SHM and continues to carry out the SHM mission,” Ms. Kroll said.

Dr. Skandhan’s accomplishments in 2020 include inviting four Alabama state representatives and three Alabama state senators to participate in a case discussion with Wiregrass Chapter leaders; creating and moderating a weekly check-in platform for the Alabama state hospital-medicine program directors’ forum through the Wiregrass Chapter – a project that enabled him to encourage the sharing of information between hospital medicine program directors; and working with the other Wiregrass Chapter leaders to launch a poster competition on Twitter with more than 80 posters presented. 
 

Hampton Roads Chapter embraces virtual connections

“I believe chapters are one of the best answers to the question: ‘What’s the value of joining SHM?’” Thomas Miller, MD, FHM, leader of the Hampton Roads Chapter, said in an interview.

“Sharing ideas and experiences with other hospitalist teams in a region, coordinating efforts to improve care, and the personal connection with others in your field are very important for hospitalists,” he emphasized. “Chapters are uniquely positioned to do just that. Recognizing individual chapters is a great way to highlight these benefits and to promote new ideas – which other chapters can incorporate into their future plans.”

The Hampton Roads Chapter demonstrated its resilience in many ways during the challenging year of 2020, Dr. Miller said.

“We love our in-person meetings,” he emphasized. “When 2020 took that away from us, we tried to make the most of the situation by embracing the reduced overhead of the virtual format to offer more specialized outreach programs, such as ‘Cultural Context Matters: How Race and Culture Impact Health Outcomes’ and ‘Critical Care: Impact of Immigration Policy on U.S. Healthcare.’ ” The critical care and immigration program “was a great outreach to our many international physicians who have faced special struggles during COVID; it not only highlighted these issues to other hospitalists, but to the broader community, since it was a joint meeting with our local World Affairs Council,” he added.

Dr. Miller also was impressed with the resilience of other chapter members, “such as our vice president, Dr. Gwen Williams, who put together a provider well-being series, ‘Hospitalist Well Being & Support in Times of Crisis.’ ” He expressed further appreciation for the multiple chapter members who supported the chapter’s virtual resident abstract/poster competition.

“Despite the limitations imposed by 2020, we have used unique approaches that have held together a strong core group while broadening outreach to new providers in our region through programs like those described,” said Dr. Miller. “At the same time, we have promoted hospital medicine to the broader community through a joint program, increased social media presence, and achieved cover articles in Hampton Roads Physician about hospital medicine and a ‘Heroes of COVID’ story featuring chapter members. We also continued our effort to add value by providing ready access to the newly state-mandated CME with ‘Opiate Prescribing in the 21st Century.’

“In a time when even family and close friends struggled to maintain connection, we found ways to offer that to our hospitalist teams, at the same time experimenting with new tools that we can put to use long after COVID is gone,” Dr. Miller added.
 

Houston Chapter supports residents, provides levity

“As a medical community, we hope that the award recognition brings more attention to the issues for which our chapter advocates,” Jeffrey W. Chen, MD, of the Houston Chapter and a hospitalist at Memorial Hermann Hospital Texas Medical Center, said in an interview.

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“We hope that it encourages more residents to pursue hospital medicine, and encourages early career hospitalists to get plugged in to the incredible opportunities our chapter offers,” he said. “We are so incredibly honored that the Society of Hospital Medicine has recognized the decade of work that has gone on to get to where we are now. We started with one officer, and we have worked so hard to grow and expand over the years so we can help support our fellow hospitalists across the city and state. 

“We are excited about what our chapter has been able to achieve,” said Dr. Chen. “We united the four internal medicine residencies around Houston and created a Houston-wide Hospitalist Interest Group to support residents, providing them the resources they need to be successful in pursuing a career in hospital medicine. We also are proud of the support we provided this year to our early career hospitalists, helping them navigate the transitions and stay up to date in topics relevant to hospital medicine. We held our biggest abstract competition yet, and held a virtual research showcase to celebrate the incredible clinical advancements still happening during the midst of the pandemic.

“It was certainly a tough and challenging year for all chapters, but despite us not being able to hold the in-person dinners that our members love so much, we were proud that we were able to have such a big year,” said Dr. Chen. “We were thankful for the physicians who led our COVID-19 talks, which provided an opportunity for hospitalists across Houston to collaborate and share ideas on which treatments and therapies were working well for their patients. During such a difficult year, we also hosted our first wellness events, including a comedian and band to bring some light during tough times.”
 

Strong leader propels team efforts

“The Chapter Exemplary Awards Program is important because it encourages higher performance while increasing membership engagement and retaining talent,” said Dr. Skandhan, of Southeast Health Medical Center in Dothan, Ala., and winner of the Most Engaged Chapter Leader award. “Being recognized as the most engaged chapter leader is an honor, especially given the national and international presence of SHM.

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“Success is achieved through the help and support of your peers and mentors, and I am fortunate to have found them through this organization,” said Dr. Skandhan. “This award brings attention to the fantastic work done by the engaged membership and leadership of the Wiregrass Chapter. This recognition makes me proud to be part of a team that prides itself on improving the quality health and wellbeing of the patients, providers, and public through innovation and collaboration; this is a testament to their work.”

Dr. Skandhan’s activities as a chapter leader included visiting health care facilities in the rural Southeastern United States. “I slowly began to learn how small towns and their economies tied into a health system, how invested the health care providers were towards their communities, and how health care disparities existed between the rural and urban populations,” he explained. “When the COVID-19 pandemic hit, I worried about these hospitals and their providers. COVID-19 was a new disease with limited understanding of the virus, treatment options, and prevention protocols.” To help smaller hospitals, the Wiregrass Chapter created a weekly check-in for hospital medicine program directors in the state of Alabama, he said.

“We would start the meeting with each participant reporting the total number of cases, ventilator usage, COVID-19 deaths, and one policy change they did that week to address a pressing issue,” Dr. Skandhan said. “Over time the meetings helped address common challenges and were a source of physician well-being.”

In addition, Dr. Skandhan and his chapter colleagues were concerned that academics were taking a back seat to the pandemic, so they rose to the challenge by designing a Twitter-based poster competition using judges from across the country. “This project was led by one of our chapter leaders, Dr. Arash Velayati of Southeast Health Medical Center,” said Dr. Skandhan. The contest included 82 posters, and the participants were able to showcase their work to a large, virtual audience.

Dr. Skandhan and colleagues also decided to partner with religious leaders in their community to help combat the spread of misinformation about COVID-19. “We teamed with the Southern Alabama Baptist Association and Interfaith Council to educate these religious leaders on the issues around COVID-19,” and addressed topics including masking and social distancing, and provided resources for religious leaders to tackle misinformation in their communities, he said.

“As chapter leaders, we need to learn to think outside the box,” Dr. Skandhan emphasized. “We can affect health care quality when we strive to solve more significant problems by bringing people together, brainstorming, and collaborating. SHM and chapter-level engagement provide us with that opportunity.“Hospitalists are often affected by the downstream effects of limited preventive care addressing chronic illnesses. Therefore, we have to strive to see the bigger picture. As we make changes at our local institutions and chapter levels, we will start seeing the improvement we hope to see in the care of our patients and our communities.”

PHM 2021 session

Leading through adversity

Presenter

Ilan Alhadeff, MD, MBA, SFHM, CLHM

Session summary

As the VP of hospitalist services and a practicing hospitalist in Boca Raton, Fla., Dr. Alhadeff shared an emotional journey where the impact of lives lost has led to organizational innovation and advocacy. He started this journey on the date of the Parkland High School shooting, Feb. 14, 2018. On this day, he lost his 14 year-old daughter Alyssa and described subsequent emotions of anger, sadness, hopelessness, and feeling the pressure to be the protector of his family. Despite receiving an outpouring of support through memorials, texts, letters, and social media posts, he was immersed in “survival mode.” He likens this to the experience many of us may be having during the pandemic. He described caring for patients with limited empathy and the impact this likely had on patient care. During this challenging time, the strongest supports became those that stated they couldn’t imagine how this event could have impacted Dr. Alhadeff’s life but offered support in any way needed – true empathic communication.

King_Erin_MN_web.jpg

“It ain’t about how hard you hit. It’s about how hard you can get hit and keep moving forward.” – Rocky Balboa (2006)

Despite the above, he and his wife founded Make Our Schools Safe (MOSS), a student-forward organization that promotes a culture of safety where all involved are counseled, “If you see something, say something.” Students are encouraged to use social media as an anonymous reporting tool. Likewise, this organization supports efforts for silent safety alerts in schools and fencing around schools to allow for 1-point entry. Lessons Dr. Alhadeff learned that might impact any pediatric hospitalist include the knowledge that mental health concerns aren’t going away; for example, after a school shooting any student affected should be provided counseling services as needed, the need to prevent triggering events, and turning grief into action can help.
 

“Life is like riding a bicycle. To keep your balance, you must keep moving.” – Albert Einstein (1930)

Dr. Alhadeff then described the process of “moving on” for him and his family. For his children, this initially meant “busying” their lives. They then gradually eased into therapy, and ultimately adopted a support dog. He experienced recurrent loss with his father passing away in March 2019, and he persevered in legislative advocacy in New Jersey and Florida and personal/professional development with work toward his MBA degree. Through this work, he collaborated with many legislators and two presidents. He describes resiliency as the ability to bounce back from adversity, with components including self-awareness, mindfulness, self-care, positive relationships, and purpose. While many of us have not had the great personal losses and challenge experienced by Dr. Alhadeff, we all are experiencing an once-in-a-lifetime transformation of health care with political and social interference. It is up to each of us to determine our role and how we can use our influence for positive change.

As noted by Dr. Alhadeff, “We are not all in the same boat. We ARE in the same storm.”
 

Key takeaways

• How PHM can promote MOSS: Allow children to be part of the work to keep schools safe. Advocate for local MOSS chapters. Support legislative advocacy for school safety.
• Despite adversity, we have the ability to demonstrate resilience. We do so through development of self-awareness, mindfulness, engagement in self-care, nurturing positive relationships, and continuing to pursue our greater purpose.

Dr. King is a pediatric hospitalist at Children’s MN and the director of medical education, an associate program director for the Pediatrics Residency program at the University of Minnesota. She received her medical degree from Wright State University Boonshoft School of Medicine and completed pediatric residency and chief residency at the University of Minnesota.

PHM 2021 session

Leading through adversity

Presenter

Ilan Alhadeff, MD, MBA, SFHM, CLHM

Session summary

As the VP of hospitalist services and a practicing hospitalist in Boca Raton, Fla., Dr. Alhadeff shared an emotional journey where the impact of lives lost has led to organizational innovation and advocacy. He started this journey on the date of the Parkland High School shooting, Feb. 14, 2018. On this day, he lost his 14 year-old daughter Alyssa and described subsequent emotions of anger, sadness, hopelessness, and feeling the pressure to be the protector of his family. Despite receiving an outpouring of support through memorials, texts, letters, and social media posts, he was immersed in “survival mode.” He likens this to the experience many of us may be having during the pandemic. He described caring for patients with limited empathy and the impact this likely had on patient care. During this challenging time, the strongest supports became those that stated they couldn’t imagine how this event could have impacted Dr. Alhadeff’s life but offered support in any way needed – true empathic communication.

King_Erin_MN_web.jpg

“It ain’t about how hard you hit. It’s about how hard you can get hit and keep moving forward.” – Rocky Balboa (2006)

Despite the above, he and his wife founded Make Our Schools Safe (MOSS), a student-forward organization that promotes a culture of safety where all involved are counseled, “If you see something, say something.” Students are encouraged to use social media as an anonymous reporting tool. Likewise, this organization supports efforts for silent safety alerts in schools and fencing around schools to allow for 1-point entry. Lessons Dr. Alhadeff learned that might impact any pediatric hospitalist include the knowledge that mental health concerns aren’t going away; for example, after a school shooting any student affected should be provided counseling services as needed, the need to prevent triggering events, and turning grief into action can help.
 

“Life is like riding a bicycle. To keep your balance, you must keep moving.” – Albert Einstein (1930)

Dr. Alhadeff then described the process of “moving on” for him and his family. For his children, this initially meant “busying” their lives. They then gradually eased into therapy, and ultimately adopted a support dog. He experienced recurrent loss with his father passing away in March 2019, and he persevered in legislative advocacy in New Jersey and Florida and personal/professional development with work toward his MBA degree. Through this work, he collaborated with many legislators and two presidents. He describes resiliency as the ability to bounce back from adversity, with components including self-awareness, mindfulness, self-care, positive relationships, and purpose. While many of us have not had the great personal losses and challenge experienced by Dr. Alhadeff, we all are experiencing an once-in-a-lifetime transformation of health care with political and social interference. It is up to each of us to determine our role and how we can use our influence for positive change.

As noted by Dr. Alhadeff, “We are not all in the same boat. We ARE in the same storm.”
 

Key takeaways

• How PHM can promote MOSS: Allow children to be part of the work to keep schools safe. Advocate for local MOSS chapters. Support legislative advocacy for school safety.
• Despite adversity, we have the ability to demonstrate resilience. We do so through development of self-awareness, mindfulness, engagement in self-care, nurturing positive relationships, and continuing to pursue our greater purpose.

Dr. King is a pediatric hospitalist at Children’s MN and the director of medical education, an associate program director for the Pediatrics Residency program at the University of Minnesota. She received her medical degree from Wright State University Boonshoft School of Medicine and completed pediatric residency and chief residency at the University of Minnesota.

PHM 2021 session

Leading through adversity

Presenter

Ilan Alhadeff, MD, MBA, SFHM, CLHM

Session summary

As the VP of hospitalist services and a practicing hospitalist in Boca Raton, Fla., Dr. Alhadeff shared an emotional journey where the impact of lives lost has led to organizational innovation and advocacy. He started this journey on the date of the Parkland High School shooting, Feb. 14, 2018. On this day, he lost his 14 year-old daughter Alyssa and described subsequent emotions of anger, sadness, hopelessness, and feeling the pressure to be the protector of his family. Despite receiving an outpouring of support through memorials, texts, letters, and social media posts, he was immersed in “survival mode.” He likens this to the experience many of us may be having during the pandemic. He described caring for patients with limited empathy and the impact this likely had on patient care. During this challenging time, the strongest supports became those that stated they couldn’t imagine how this event could have impacted Dr. Alhadeff’s life but offered support in any way needed – true empathic communication.

King_Erin_MN_web.jpg

“It ain’t about how hard you hit. It’s about how hard you can get hit and keep moving forward.” – Rocky Balboa (2006)

Despite the above, he and his wife founded Make Our Schools Safe (MOSS), a student-forward organization that promotes a culture of safety where all involved are counseled, “If you see something, say something.” Students are encouraged to use social media as an anonymous reporting tool. Likewise, this organization supports efforts for silent safety alerts in schools and fencing around schools to allow for 1-point entry. Lessons Dr. Alhadeff learned that might impact any pediatric hospitalist include the knowledge that mental health concerns aren’t going away; for example, after a school shooting any student affected should be provided counseling services as needed, the need to prevent triggering events, and turning grief into action can help.
 

“Life is like riding a bicycle. To keep your balance, you must keep moving.” – Albert Einstein (1930)

Dr. Alhadeff then described the process of “moving on” for him and his family. For his children, this initially meant “busying” their lives. They then gradually eased into therapy, and ultimately adopted a support dog. He experienced recurrent loss with his father passing away in March 2019, and he persevered in legislative advocacy in New Jersey and Florida and personal/professional development with work toward his MBA degree. Through this work, he collaborated with many legislators and two presidents. He describes resiliency as the ability to bounce back from adversity, with components including self-awareness, mindfulness, self-care, positive relationships, and purpose. While many of us have not had the great personal losses and challenge experienced by Dr. Alhadeff, we all are experiencing an once-in-a-lifetime transformation of health care with political and social interference. It is up to each of us to determine our role and how we can use our influence for positive change.

As noted by Dr. Alhadeff, “We are not all in the same boat. We ARE in the same storm.”
 

Key takeaways

• How PHM can promote MOSS: Allow children to be part of the work to keep schools safe. Advocate for local MOSS chapters. Support legislative advocacy for school safety.
• Despite adversity, we have the ability to demonstrate resilience. We do so through development of self-awareness, mindfulness, engagement in self-care, nurturing positive relationships, and continuing to pursue our greater purpose.

Dr. King is a pediatric hospitalist at Children’s MN and the director of medical education, an associate program director for the Pediatrics Residency program at the University of Minnesota. She received her medical degree from Wright State University Boonshoft School of Medicine and completed pediatric residency and chief residency at the University of Minnesota.

PHM 2021 session

Accelerating Patient Care and Healthcare Workforce Diversity and Inclusion

Presenter

Julie Silver, MD

Session summary

Gender inequity in medicine has been well documented and further highlighted by the tremendous impact of the COVID-19 pandemic on women in medicine. While more women than men are entering medical schools across the U.S., women still struggle to reach the highest levels of academic rank, achieve leadership positions of power and influence, receive fair equitable pay, attain leadership roles in national societies, and receive funding from national agencies. They also continue to face discrimination and implicit and explicit biases. Women of color or from other minority backgrounds face even greater barriers and biases. Despite being a specialty in which women represent almost 70% of the workforce, pediatrics is not immune to these disparities.

Casillas_Carlos_OH_21_web.jpg

In her PHM21 plenary on Aug. 3, 2021, Dr. Julie Silver, a national expert in gender equity disparities, detailed the landscape for women in medicine and proposed some solutions to accelerate systemic change for gender equity. In order to understand and mitigate gender inequity, Dr. Silver encouraged the PHM community to identify influential “gatekeepers” of promotion, advancement, and salary compensation. In academic medicine medical schools, funding agencies, professional societies, and journals are the gatekeepers to advancement and compensation for women. Women are traditionally underrepresented as members and influential leaders of these gatekeeping organizations and in their recognition structures, therefore their advancement, compensation, and wellbeing are hindered.

OToole_Jennifer_OH_21_web.jpg

Key takeaways

• Critical mass theory will not help alleviate gender inequity in medicine, as women make up a critical mass in pediatrics and are still experiencing stark inequities. Critical actor leaders are needed to highlight disparities and drive change even once a critical mass is reached.
• Our current diversity, equity, and inclusion (DEI) efforts are ineffective and are creating an “illusion of fairness that causes majority group members to become less sensitive to recognizing discrimination against minorities.” Many of the activities that are considered citizenship, including committees focused on DEI efforts, should be counted as scholarship, and appropriately compensated to ensure promotion of our women and minority colleagues.
• Male allies are critical to documenting, disseminating, and addressing gender inequality. Without the support of men in the field, we will see little progress.
• While there are numerous advocacy angles we can take when advocating for gender equity, the most effective will be the financial angle. Gender pay gaps at the start of a career can lead to roughly 2 million dollars of salary loss for a woman over the course of her career. In order to alleviate those salary pay gaps our institutions must not expect women to negotiate for fair pay, make salary benchmarks transparent, continue to monitor and conduct research on compensation disparities, and attempt to alleviate the weight of educational debt.
• COVID-19 is causing immense stress on women in medicine, and the impact could be disastrous. We must recognize and reward the “4th shift” women are working for COVID-19–related activities at home and at work, and put measures in place to #GiveHerAReasonToStay in health care.
• Men and other women leaders have a responsibility to sponsor the many and well-qualified women in medicine for awards, committees, and speaking engagements. These opportunities are key markers of success in academic medicine and are critical to advancement and salary compensation.

Dr. Casillas is the internal medicine-pediatric chief resident for the University of Cincinnati/Cincinnati Children’s Internal Medicine-Pediatric program. His career goal is to serve as a hospitalist for children and adults, and he is interested in health equity and Latinx health. Dr. O’Toole is a pediatric and adult hospitalist at Cincinnati Children’s Hospital Medical Center and University of Cincinnati Medical Center, and a professor of pediatrics and internal medicine at the University of Cincinnati College of Medicine. She serves as program director of Cincinnati’s Combined Internal Medicine and Pediatrics Residency Program.

PHM 2021 session

Accelerating Patient Care and Healthcare Workforce Diversity and Inclusion

Presenter

Julie Silver, MD

Session summary

Gender inequity in medicine has been well documented and further highlighted by the tremendous impact of the COVID-19 pandemic on women in medicine. While more women than men are entering medical schools across the U.S., women still struggle to reach the highest levels of academic rank, achieve leadership positions of power and influence, receive fair equitable pay, attain leadership roles in national societies, and receive funding from national agencies. They also continue to face discrimination and implicit and explicit biases. Women of color or from other minority backgrounds face even greater barriers and biases. Despite being a specialty in which women represent almost 70% of the workforce, pediatrics is not immune to these disparities.

Casillas_Carlos_OH_21_web.jpg

In her PHM21 plenary on Aug. 3, 2021, Dr. Julie Silver, a national expert in gender equity disparities, detailed the landscape for women in medicine and proposed some solutions to accelerate systemic change for gender equity. In order to understand and mitigate gender inequity, Dr. Silver encouraged the PHM community to identify influential “gatekeepers” of promotion, advancement, and salary compensation. In academic medicine medical schools, funding agencies, professional societies, and journals are the gatekeepers to advancement and compensation for women. Women are traditionally underrepresented as members and influential leaders of these gatekeeping organizations and in their recognition structures, therefore their advancement, compensation, and wellbeing are hindered.

OToole_Jennifer_OH_21_web.jpg

Key takeaways

• Critical mass theory will not help alleviate gender inequity in medicine, as women make up a critical mass in pediatrics and are still experiencing stark inequities. Critical actor leaders are needed to highlight disparities and drive change even once a critical mass is reached.
• Our current diversity, equity, and inclusion (DEI) efforts are ineffective and are creating an “illusion of fairness that causes majority group members to become less sensitive to recognizing discrimination against minorities.” Many of the activities that are considered citizenship, including committees focused on DEI efforts, should be counted as scholarship, and appropriately compensated to ensure promotion of our women and minority colleagues.
• Male allies are critical to documenting, disseminating, and addressing gender inequality. Without the support of men in the field, we will see little progress.
• While there are numerous advocacy angles we can take when advocating for gender equity, the most effective will be the financial angle. Gender pay gaps at the start of a career can lead to roughly 2 million dollars of salary loss for a woman over the course of her career. In order to alleviate those salary pay gaps our institutions must not expect women to negotiate for fair pay, make salary benchmarks transparent, continue to monitor and conduct research on compensation disparities, and attempt to alleviate the weight of educational debt.
• COVID-19 is causing immense stress on women in medicine, and the impact could be disastrous. We must recognize and reward the “4th shift” women are working for COVID-19–related activities at home and at work, and put measures in place to #GiveHerAReasonToStay in health care.
• Men and other women leaders have a responsibility to sponsor the many and well-qualified women in medicine for awards, committees, and speaking engagements. These opportunities are key markers of success in academic medicine and are critical to advancement and salary compensation.

Dr. Casillas is the internal medicine-pediatric chief resident for the University of Cincinnati/Cincinnati Children’s Internal Medicine-Pediatric program. His career goal is to serve as a hospitalist for children and adults, and he is interested in health equity and Latinx health. Dr. O’Toole is a pediatric and adult hospitalist at Cincinnati Children’s Hospital Medical Center and University of Cincinnati Medical Center, and a professor of pediatrics and internal medicine at the University of Cincinnati College of Medicine. She serves as program director of Cincinnati’s Combined Internal Medicine and Pediatrics Residency Program.

PHM 2021 session

Accelerating Patient Care and Healthcare Workforce Diversity and Inclusion

Presenter

Julie Silver, MD

Session summary

Gender inequity in medicine has been well documented and further highlighted by the tremendous impact of the COVID-19 pandemic on women in medicine. While more women than men are entering medical schools across the U.S., women still struggle to reach the highest levels of academic rank, achieve leadership positions of power and influence, receive fair equitable pay, attain leadership roles in national societies, and receive funding from national agencies. They also continue to face discrimination and implicit and explicit biases. Women of color or from other minority backgrounds face even greater barriers and biases. Despite being a specialty in which women represent almost 70% of the workforce, pediatrics is not immune to these disparities.

Casillas_Carlos_OH_21_web.jpg

In her PHM21 plenary on Aug. 3, 2021, Dr. Julie Silver, a national expert in gender equity disparities, detailed the landscape for women in medicine and proposed some solutions to accelerate systemic change for gender equity. In order to understand and mitigate gender inequity, Dr. Silver encouraged the PHM community to identify influential “gatekeepers” of promotion, advancement, and salary compensation. In academic medicine medical schools, funding agencies, professional societies, and journals are the gatekeepers to advancement and compensation for women. Women are traditionally underrepresented as members and influential leaders of these gatekeeping organizations and in their recognition structures, therefore their advancement, compensation, and wellbeing are hindered.

OToole_Jennifer_OH_21_web.jpg

Key takeaways

• Critical mass theory will not help alleviate gender inequity in medicine, as women make up a critical mass in pediatrics and are still experiencing stark inequities. Critical actor leaders are needed to highlight disparities and drive change even once a critical mass is reached.
• Our current diversity, equity, and inclusion (DEI) efforts are ineffective and are creating an “illusion of fairness that causes majority group members to become less sensitive to recognizing discrimination against minorities.” Many of the activities that are considered citizenship, including committees focused on DEI efforts, should be counted as scholarship, and appropriately compensated to ensure promotion of our women and minority colleagues.
• Male allies are critical to documenting, disseminating, and addressing gender inequality. Without the support of men in the field, we will see little progress.
• While there are numerous advocacy angles we can take when advocating for gender equity, the most effective will be the financial angle. Gender pay gaps at the start of a career can lead to roughly 2 million dollars of salary loss for a woman over the course of her career. In order to alleviate those salary pay gaps our institutions must not expect women to negotiate for fair pay, make salary benchmarks transparent, continue to monitor and conduct research on compensation disparities, and attempt to alleviate the weight of educational debt.
• COVID-19 is causing immense stress on women in medicine, and the impact could be disastrous. We must recognize and reward the “4th shift” women are working for COVID-19–related activities at home and at work, and put measures in place to #GiveHerAReasonToStay in health care.
• Men and other women leaders have a responsibility to sponsor the many and well-qualified women in medicine for awards, committees, and speaking engagements. These opportunities are key markers of success in academic medicine and are critical to advancement and salary compensation.

Dr. Casillas is the internal medicine-pediatric chief resident for the University of Cincinnati/Cincinnati Children’s Internal Medicine-Pediatric program. His career goal is to serve as a hospitalist for children and adults, and he is interested in health equity and Latinx health. Dr. O’Toole is a pediatric and adult hospitalist at Cincinnati Children’s Hospital Medical Center and University of Cincinnati Medical Center, and a professor of pediatrics and internal medicine at the University of Cincinnati College of Medicine. She serves as program director of Cincinnati’s Combined Internal Medicine and Pediatrics Residency Program.

The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.

Hadvani_Teena_HOUSTON_web.jpg

But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.

Uremovich_Vicki_Tex_web.jpg

Disaster preparedness and assessing ongoing needs

Disaster preparedness cycle and Hazard Vulnerability Assessment

The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.^1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.

Quinonez_Ricardo_Tex_web.jpg

The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.^6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”⁷

Disaster preparedness staffing considerations

Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.⁸

Lopez_Michelle_A_HOUSTON_web.jpg

To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.^9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.

Mothner_Brent_HOUSTON_web.jpg

Dynamic disaster response

Supporting patient and hospital needs

The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.

As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.

Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.¹¹ Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.

Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
 

Unique staffing situations related to COVID-19

Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.¹² Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.

We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.

Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.

Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
 

Preparing for the next disaster during the pandemic

This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.^13-15

How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.

Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”⁹ This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
 

Conclusion

Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.

Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.

References

1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.

2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.

3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.

4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.

5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.

6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.

7. Hospital Association of Southern California. Hazard and vulnerability analysis.

8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.

9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.

10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.

11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.

12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.

13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.

14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.

15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.

The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.

Hadvani_Teena_HOUSTON_web.jpg

But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.

Uremovich_Vicki_Tex_web.jpg

Disaster preparedness and assessing ongoing needs

Disaster preparedness cycle and Hazard Vulnerability Assessment

The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.^1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.

Quinonez_Ricardo_Tex_web.jpg

The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.^6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”⁷

Disaster preparedness staffing considerations

Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.⁸

Lopez_Michelle_A_HOUSTON_web.jpg

To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.^9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.

Mothner_Brent_HOUSTON_web.jpg

Dynamic disaster response

Supporting patient and hospital needs

The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.

As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.

Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.¹¹ Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.

Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
 

Unique staffing situations related to COVID-19

Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.¹² Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.

We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.

Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.

Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
 

Preparing for the next disaster during the pandemic

This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.^13-15

How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.

Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”⁹ This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
 

Conclusion

Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.

Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.

References

1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.

2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.

3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.

4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.

5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.

6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.

7. Hospital Association of Southern California. Hazard and vulnerability analysis.

8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.

9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.

10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.

11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.

12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.

13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.

14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.

15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.

The COVID-19 pandemic has tested disaster preparedness in hospitals across the nation. The pandemic brought many unique disaster planning challenges not commonly seen with other emergencies disasters. These included an uncertain and prolonged time frame, the implementation of physical distancing, and the challenges of preserving the health care work force.

Hadvani_Teena_HOUSTON_web.jpg

But how do we prepare for the next disaster when the health care system and staff are already stretched thin? Here, we discuss the concept of maintaining a state of preparedness through and beyond COVID-19, using a disaster preparedness cycle – including continuous assessments of vulnerabilities, dynamic staffing adjustments to support patient and hospital needs, and broadening of the pandemic response to incorporate planning for the next disaster.

Uremovich_Vicki_Tex_web.jpg

Disaster preparedness and assessing ongoing needs

Disaster preparedness cycle and Hazard Vulnerability Assessment

The disaster preparedness cycle illustrates that disaster preparedness is continuous. Disaster preparedness is achieved with the non-stop cycle of planning, coordinating, and recognizing vulnerable areas.^1-5 Hazard vulnerability analysis (HVA) can play a critical role in recognizing areas in which a hospital system has strengths and weaknesses for different disaster scenarios. There are several tools available, but the overarching goal is to provide an objective and systematic approach to evaluate the potential damage and impact a disaster could have on the health care system and surrounding community.

Quinonez_Ricardo_Tex_web.jpg

The HVA can also be utilized to reassess system or personnel vulnerabilities that may have been exposed or highlighted during the pandemic.^6,7 These vulnerabilities must be addressed during preparations for the next disaster while concurrently “assuming the incident happens at the worst possible time.”⁷

Disaster preparedness staffing considerations

Management, communication, and staffing issues are critical to disaster response. Key leadership responses during COVID-19 included providing frequent and transparent communication, down-staffing for physical distancing during low census, and prioritizing staff well-being. These measures serve as a strong foundation moving into preparations for the next disaster.⁸

Lopez_Michelle_A_HOUSTON_web.jpg

To ensure adequate staffing during an unexpected natural disaster, we recommend creating “ride-out” and “relief teams” as part of disaster staffing preparedness.^9,10 The ride-out team provides the initial care and these providers are expected to stay in the hospital during the primary impact of the event. Once the initial threat of disaster is over and it is deemed safe to travel, the relief team is activated and offers reprieve to the ride-out team. Leaders and backup leaders within these teams should be identified in the event teams are activated. These assignments should be made at the start of the year and updated yearly or more frequently, if needed.

Mothner_Brent_HOUSTON_web.jpg

Dynamic disaster response

Supporting patient and hospital needs

The next step in the disaster preparedness cycle is adjusting to changing needs during the disaster. The pediatric inpatient population was less affected initially by COVID-19, allowing hospitalists to support the unpredicted needs of the pandemic. A dynamic and flexible physician response is important to disaster preparedness.

As there has been a continued shift to telehealth during the pandemic, our group has engaged in telehealth calls related to COVID-19. Seizing these new opportunities not only provided additional services to our patients, but also strengthened community support, physician worth, and the hospital’s financial state. This is also an opportunity for higher-risk clinicians or quarantined faculty to offer patient care during the pandemic.

Cram et al. describe the importance of “unspecializing” during the COVID-19 pandemic.¹¹ Starting discussions early with adult and pediatric critical care colleagues is vital. Hospitalists take care of a broad patient population, and therefore, can adapt to where the clinical need may be. Optimizing and expanding our skill sets can bring value to the hospital system during uncertain times.

Hospitalists are also instrumental for patient flow during the pandemic. To address this, our group partnered with hospital leadership from many different areas including administration, nursing, emergency medicine, critical care, and ancillary services. By collaborating as one cohesive hospital unit, we were able to efficiently develop, implement, and update best clinical care guidelines and algorithms for COVID-19–related topics such as testing indications, admission criteria, infection control, and proper personal protective equipment use. Lastly, working with specialists to consolidate teams during a pandemic presents an opportunity for hospitalists to highlight expertise while bringing value to the hospital.
 

Unique staffing situations related to COVID-19

Different from other disasters, the COVID-19 pandemic affected older or immunocompromised staff in a unique way. Beauhaus et al. note that 20% of the physician workforce in the United Sates is between 55 and 64 years of age, and 9% are 65 years and older.¹² Hospitalist groups should focus on how to optimize and preserve their workforce, specifically those that are higher risk due to age or other health conditions.

We used a tiered guide to safely accommodate our physicians that were determined to be at higher-risk for complications of COVID-19; these recommendations included limiting exposure to patients with acute respiratory illnesses and shifting some providers to a different clinical environments with a lower exposure risk, such as telemedicine visits.

Other COVID-19 preparedness considerations that affected our group in particular include the changes in learner staffing. Similar to attending down-staffing to encourage physical distancing during low census, learners (residents, medical students, and physician assistant students) also experienced decreased hours or suspension of rotations. To maintain optimal patient care, adjusting to changing disaster needs may include assessing attendings’ capacity to assume responsibilities typically supported by learners.

Due to the ongoing nature of the pandemic, we have had to maintain a dynamic response while adjusting to changing and ongoing needs during recovery. Creating a measured and staggered approach helps facilitate a smooth transition back to nonemergent activities. The education of learners, academic and scholarly work, and administrative duties will resume, but likely in a different steady state. Also, awareness of physician burnout and fatigue is critical as an institution enters a phase of recovery.
 

Preparing for the next disaster during the pandemic

This brings us back to the beginning of the disaster preparedness cycle and the need to plan for the next disaster. Current disaster preparedness plans among physician groups and hospitals are likely focused on an individual disaster scenario, but adjusting current disaster plans to account for the uncertain time frame of an event like the COVID-19 pandemic is critical. Several articles in the national news posed similar questions, although these publications focused mainly on the Federal Emergency Management Agency and the governmental response to prepare for the next disaster when resources are already stretched.^13-15

How do we adequately plan, maintain a dynamic response, and continue to efficiently move through the disaster staffing cycle during an event like the COVID-19 pandemic? Being aware of current vulnerabilities and addressing gaps at the department and hospital level are vital to disaster preparedness. For example, we reassessed disaster (ride-out/relief) teams and the minimum number of staff needed to maintain safe and quality care, and what in-house arrangements would be needed (food, supplies, sleeping arrangements) while having to maintain physical distance.

Newman et al. explain “in disaster planning, having as many physicians as possible on hand may seem like an advantage, but being overstaffed in tight quarters was almost as bad as being understaffed.”⁹ This has been particularly true during the COVID-19 pandemic. It is crucial to have backup plans for faculty that are unable to serve ride-out duties from unexpected issues – such as availability, illnesses/quarantines, childcare/dependents. Also, it is important to be aware that some supply chains are already strained because of the pandemic and how this may play a role in the availability of certain supplies. Being aware and proactive about specific constraints allows for a better level of preparedness. Continued collaboration and communication with other services to provide care should be ongoing throughout the disaster preparedness cycle.
 

Conclusion

Providing and maintaining optimal and safe patient care should be the overarching goal throughout disaster preparedness. Being aware of group and institutional vulnerabilities, collaboration with hospital leadership, and remaining flexible as hospitalists are critical components for successful preparedness amid disasters. A dynamic and responsive disaster plan has been vital amid COVID-19, and for the next disasters we will certainly encounter.

Dr. Hadvani is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Uremovich is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Quinonez is associate professor of pediatrics and chief of pediatric hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Lopez is assistant professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital. Dr. Mothner is associate professor of pediatrics in the section of hospital medicine at Baylor College of Medicine, Texas Children’s Hospital and is the pediatric hospital medicine medical director for the main campus.

References

1. Malilay J et al. The role of applied epidemiology methods in the disaster management cycle. Am J Public Health. 2014;104(11):2092-102. doi: 10.2105/AJPH.2014.302010.

2. Federal Emergency Management Agency. Developing and maintaining emergency operations plans. 2010 Nov.

3. Federal Emergency Management Agency. National preparedness system. 2020 Jul 31.

4. Federal Emergency Management Agency. National preparedness goal. 2011 Sep.

5. Environmental health in emergencies and disasters: A practical guide. World Health Organization, Geneva. 2002:9-24. Edited by B. Wisner and J. Adams.

6. U.S. Department of Health and Human Services. Topic collection: Hazard vulnerability/risk assessment.

7. Hospital Association of Southern California. Hazard and vulnerability analysis.

8. Meier K et al. Pediatric hospital medicine management, staffing, and well-being in the face of COVID-19. J Hosp Med. 2020 May;15(5):308-10. doi: 10.12788/jhm.3435.

9. Newman B and Gallion C. Hurricane Harvey: Firsthand preparedness in graduate medical education. Acad Med. 2019 Sep;94(9):1267-69. doi: 10.1097/ACM.0000000000002696.

10. Brevard S et al. Analysis of disaster response plans and the aftermath of Hurricane Katrina: Lessons learned from a level I trauma center. J Trauma. 2008 Nov;65(5):1126-32. doi: 10.1097/TA.0b013e318188d6e5.

11. Cram P et al. All hands on deck learning to “un-specialize” in the COVID-19 pandemic. J Hosp Med. 2020 May;15(5):314-5. doi: 10.12788/jhm.3426.

12. Buerhaus P et al. Older clinicians and the surge in novel coronavirus disease 2019 (COVID-19). JAMA. 2020 May 12;323(18):1777-8. doi: 10.1001/jama.2020.4978.

13. VOX Media. Imagine Hurricane Katrina during a pandemic. The US needs to prepare for that – now. 2020 May 27.

14. The Hill. Democratic lawmakers ask how FEMA is planning to balance natural disasters, COVID-19 response. 2020 Apr 20.

15. The Atlantic. What happens if a ‘big one’ strikes during the pandemic? 2020 May 9.

Editor’s note: In this article, we present an archetypal ethics challenge in hospital medicine. The authors, members of the SHM’s Ethics Special Interest Group and clinical ethics consultants at their respective hospitals, will comment on the questions and practical approaches for hospitalists.

Ms. S, an 82-year-old woman with severe dementia, was initially hospitalized in the ICU with acute on chronic respiratory failure. Prior to admission, Ms. S lived with her daughter, who is her primary caregiver. Ms. S is able to say her daughter’s name, and answer “yes” and “no” to simple questions. She is bed bound, incontinent of urine and feces, and dependent on her daughter for all ADLs.

This admission, Ms. S has been re-intubated 4 times for recurrent respiratory failure. The nursing staff are distressed that she is suffering physically. Her daughter requests to continue all intensive, life-prolonging treatment including mechanical ventilation and artificial nutrition.

During sign out, your colleague remarks that his grandmother was in a similar situation and that his family chose to pursue comfort care. He questions whether Ms. S has any quality of life and asks if you think further intensive care is futile.

On your first day caring for Ms. S, you contact her primary care provider. Her PCP reports that Ms. S and her daughter completed an advance directive (AD) 10 years ago which documents a preference for all life prolonging treatment.
 

Question #1: What are the ethical challenges?

Dr. Chase: In caring for Ms. S, we face a common ethical challenge: how to respect the patient’s prior preferences (autonomy) when the currently requested treatments have diminishing benefits (beneficence) and escalating harms (non-maleficence). Life-prolonging care can have diminishing returns at the end of life. Ms. S’s loss of decision-making capacity adds a layer of complexity. Her AD was completed when she was able to consider decisions about her care, and she might make different decisions in her current state of health. Shared decision-making with a surrogate can be complicated by a surrogate’s anxiety with making life-altering decisions or their desire to avoid guilt or loneliness. Health care professionals face the limits of scientific knowledge in delivering accurate prognostic estimates, probabilities of recovery, and likelihood of benefit from interventions. In addition to the guideposts of ethical principles, some hospitals have policies which advise clinicians to avoid non-beneficial care.

Chase_Jack_CA_web.jpg

Such situations are emotionally intense and can trigger distress among patients, families, caregivers and health care professionals. Conscious and unconscious bias about a patient’s perceived quality of life undermines equity and can play a role in our recommendations for patients of advanced age, with cognitive impairment, and those who live with a disability.
 

Question #2: How might you meet the patient’s medical needs in line with her goals?

Dr. Khawaja: In order to provide care consistent with the patient’s goals, the first step is to clarify these goals with Ms. S’s surrogate decision-maker, her daughter. In a previously autonomous but presently incapacitated patient, the previously expressed preferences in the form of a written AD should be respected. However, the AD is only a set of preferences completed at a particular time, not medical orders. The clinician and surrogate must consider how to apply the AD to the current clinical circumstances. The clinician should verify that the clinical circumstances specified in the AD have been met and evaluate if the patient’s preferences have changed since she originally completed the AD.

Khawaja_Lubna_TX_web.jpg

Surrogates are asked to use a Substituted Judgement Standard (i.e., what would the patient choose in this situation if known). This may differ from what the surrogate wants. If not known, surrogates are asked to use the Best Interest Standard (i.e., what would bring the most net benefit to the patient by weighing benefits and risks of treatment options). I often ask the surrogate, “Tell us about your loved one.” Or, “Knowing your loved one, what do you think would be the most important for her right now?”¹

I would also caution against bias in judging quality of life in patients with dementia, and using the term “futility,” as these concepts are inherently subjective. In general, when a colleague raises the issue of futility, I begin by asking, “…futile to achieve what goal?” That can help clarify some of the disagreement as some goals can be accomplished while others cannot.

Finally, I work to include other members of our team in these discussions. The distress of nurses, social workers, and others are important to acknowledge, validate, and involve in the problem-solving process.
 

Question #3: If you were Ms. S’s hospitalist, what would you do?

Dr. Khawaja: As the hospitalist caring for Ms. S, I would use the “four boxes” model as a helpful, clinically relevant and systematic approach to managing ethical concerns.²

This “four boxes” model gives us a practical framework to address these ethical principles by asking questions in four domains.

Medical indications: What is the nature of her current illness, and is it reversible or not? What is the probability of success of treatment options like mechanical ventilation? Are there adverse effects of treatment?

Patient preferences: Since Ms. S lacks capacity, does her daughter understand the benefits and burdens of treatment? What are the goals of treatment? Prolonging life? Minimizing discomfort? Spending time with loved ones? What burdens would the patient be willing to endure to reach her goals?

Quality of life: What would the patient’s quality of life be with and without the treatments?

Contextual features: My priorities would be building a relationship of trust with Ms. S’s daughter – by educating her about her mother’s clinical status, addressing her concerns and questions, and supporting her as we work through patient-centered decisions about what is best for her mother. Honest communication is a must, even if it means acknowledging uncertainties about the course of disease and prognosis.

These are not easy decisions for surrogates to make. They should be given time to process information and to make what they believe are the best decisions for their loved ones. It is critical for clinicians to provide honest and complete clinical information and to avoid value judgments, bias, or unreasonable time pressure. While one-on-one conversations are central, I find that multidisciplinary meetings allow all stakeholders to ask and answer vital questions and ideally to reach consensus in treatment planning.

Dr. Chase: In caring for Ms. S, I would use a structured approach to discussions with her daughter, such as the “SPIKES” protocol.³ Using open ended questions, I would ask about the patient’s and her daughter’s goals, values, and fears and provide support about the responsibility for shared-decision making and the difficulty of uncertainty. Reflecting statements can help in confirming understanding and showing attention (e.g. “I hear that avoiding discomfort would be important to your mother.”)

I find it helpful to emphasize my commitment to honesty and non-abandonment (a common fear among patients and families). By offering to provide recommendations about both disease-directed and palliative, comfort-focused interventions, the patient’s daughter has an opportunity to engage voluntarily in discussion. When asked about care that may have marginal benefit, I suggest time-limited trials.⁴ I do not offer non-beneficial treatments and if asked about such treatments, I note the underlying motive and why the treatment is not feasible (“I see that you are hoping that your mother will live longer, but I am concerned that tube feeding will not help because…”), offer preferable alternatives, and leave space for questions and emotions. It is important not to force a premature resolution of the situation through unilateral or coercive decisions⁵ (i.e., going off service does not mean I have to wrap up the existential crisis which is occurring.) A broader challenge is the grief and other emotions which accompany illness and death. I can neither prevent death nor grief, but I can offer my professional guidance and provide a supportive space for the patient and family to experience this transition. By acknowledging this, I center myself with the patient and family and we can work together toward a common goal of providing compassionate and ethical care.

Dr. Chase is associate professor, Department of Family and Community Medicine, University of California San Francisco; and co-chair, Ethics Committee, San Francisco General Hospital. Dr. Khawaja is assistant professor, Department of Internal Medicine, Baylor College of Medicine, Houston, and a member of the Ethics Committee of the Society of General Internal Medicine.

References

1. Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010 Nov 3;304(17):1946-7. doi: 10.1001/jama.2010.159.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 6th ed. New York: McGraw Hill Medical; 2006.

3. Baile WF, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. doi: 10.1634/theoncologist.5-4-302.

4. Chang DW, et al. Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments. JAMA Intern Med. 2021;181(6):786–794. doi: 10.1001/jamainternmed.2021.1000.

5. Sedig, L. What’s the role of autonomy in patient-and family-centered care when patients and family members don’t agree? AMA J Ethics. 2016;18(1):12-17. doi: 10.1001/journalofethics.2017.18.1.ecas2-1601.

Editor’s note: In this article, we present an archetypal ethics challenge in hospital medicine. The authors, members of the SHM’s Ethics Special Interest Group and clinical ethics consultants at their respective hospitals, will comment on the questions and practical approaches for hospitalists.

Ms. S, an 82-year-old woman with severe dementia, was initially hospitalized in the ICU with acute on chronic respiratory failure. Prior to admission, Ms. S lived with her daughter, who is her primary caregiver. Ms. S is able to say her daughter’s name, and answer “yes” and “no” to simple questions. She is bed bound, incontinent of urine and feces, and dependent on her daughter for all ADLs.

This admission, Ms. S has been re-intubated 4 times for recurrent respiratory failure. The nursing staff are distressed that she is suffering physically. Her daughter requests to continue all intensive, life-prolonging treatment including mechanical ventilation and artificial nutrition.

During sign out, your colleague remarks that his grandmother was in a similar situation and that his family chose to pursue comfort care. He questions whether Ms. S has any quality of life and asks if you think further intensive care is futile.

On your first day caring for Ms. S, you contact her primary care provider. Her PCP reports that Ms. S and her daughter completed an advance directive (AD) 10 years ago which documents a preference for all life prolonging treatment.
 

Question #1: What are the ethical challenges?

Dr. Chase: In caring for Ms. S, we face a common ethical challenge: how to respect the patient’s prior preferences (autonomy) when the currently requested treatments have diminishing benefits (beneficence) and escalating harms (non-maleficence). Life-prolonging care can have diminishing returns at the end of life. Ms. S’s loss of decision-making capacity adds a layer of complexity. Her AD was completed when she was able to consider decisions about her care, and she might make different decisions in her current state of health. Shared decision-making with a surrogate can be complicated by a surrogate’s anxiety with making life-altering decisions or their desire to avoid guilt or loneliness. Health care professionals face the limits of scientific knowledge in delivering accurate prognostic estimates, probabilities of recovery, and likelihood of benefit from interventions. In addition to the guideposts of ethical principles, some hospitals have policies which advise clinicians to avoid non-beneficial care.

Chase_Jack_CA_web.jpg

Such situations are emotionally intense and can trigger distress among patients, families, caregivers and health care professionals. Conscious and unconscious bias about a patient’s perceived quality of life undermines equity and can play a role in our recommendations for patients of advanced age, with cognitive impairment, and those who live with a disability.
 

Question #2: How might you meet the patient’s medical needs in line with her goals?

Dr. Khawaja: In order to provide care consistent with the patient’s goals, the first step is to clarify these goals with Ms. S’s surrogate decision-maker, her daughter. In a previously autonomous but presently incapacitated patient, the previously expressed preferences in the form of a written AD should be respected. However, the AD is only a set of preferences completed at a particular time, not medical orders. The clinician and surrogate must consider how to apply the AD to the current clinical circumstances. The clinician should verify that the clinical circumstances specified in the AD have been met and evaluate if the patient’s preferences have changed since she originally completed the AD.

Khawaja_Lubna_TX_web.jpg

Surrogates are asked to use a Substituted Judgement Standard (i.e., what would the patient choose in this situation if known). This may differ from what the surrogate wants. If not known, surrogates are asked to use the Best Interest Standard (i.e., what would bring the most net benefit to the patient by weighing benefits and risks of treatment options). I often ask the surrogate, “Tell us about your loved one.” Or, “Knowing your loved one, what do you think would be the most important for her right now?”¹

I would also caution against bias in judging quality of life in patients with dementia, and using the term “futility,” as these concepts are inherently subjective. In general, when a colleague raises the issue of futility, I begin by asking, “…futile to achieve what goal?” That can help clarify some of the disagreement as some goals can be accomplished while others cannot.

Finally, I work to include other members of our team in these discussions. The distress of nurses, social workers, and others are important to acknowledge, validate, and involve in the problem-solving process.
 

Question #3: If you were Ms. S’s hospitalist, what would you do?

Dr. Khawaja: As the hospitalist caring for Ms. S, I would use the “four boxes” model as a helpful, clinically relevant and systematic approach to managing ethical concerns.²

This “four boxes” model gives us a practical framework to address these ethical principles by asking questions in four domains.

Medical indications: What is the nature of her current illness, and is it reversible or not? What is the probability of success of treatment options like mechanical ventilation? Are there adverse effects of treatment?

Patient preferences: Since Ms. S lacks capacity, does her daughter understand the benefits and burdens of treatment? What are the goals of treatment? Prolonging life? Minimizing discomfort? Spending time with loved ones? What burdens would the patient be willing to endure to reach her goals?

Quality of life: What would the patient’s quality of life be with and without the treatments?

Contextual features: My priorities would be building a relationship of trust with Ms. S’s daughter – by educating her about her mother’s clinical status, addressing her concerns and questions, and supporting her as we work through patient-centered decisions about what is best for her mother. Honest communication is a must, even if it means acknowledging uncertainties about the course of disease and prognosis.

These are not easy decisions for surrogates to make. They should be given time to process information and to make what they believe are the best decisions for their loved ones. It is critical for clinicians to provide honest and complete clinical information and to avoid value judgments, bias, or unreasonable time pressure. While one-on-one conversations are central, I find that multidisciplinary meetings allow all stakeholders to ask and answer vital questions and ideally to reach consensus in treatment planning.

Dr. Chase: In caring for Ms. S, I would use a structured approach to discussions with her daughter, such as the “SPIKES” protocol.³ Using open ended questions, I would ask about the patient’s and her daughter’s goals, values, and fears and provide support about the responsibility for shared-decision making and the difficulty of uncertainty. Reflecting statements can help in confirming understanding and showing attention (e.g. “I hear that avoiding discomfort would be important to your mother.”)

I find it helpful to emphasize my commitment to honesty and non-abandonment (a common fear among patients and families). By offering to provide recommendations about both disease-directed and palliative, comfort-focused interventions, the patient’s daughter has an opportunity to engage voluntarily in discussion. When asked about care that may have marginal benefit, I suggest time-limited trials.⁴ I do not offer non-beneficial treatments and if asked about such treatments, I note the underlying motive and why the treatment is not feasible (“I see that you are hoping that your mother will live longer, but I am concerned that tube feeding will not help because…”), offer preferable alternatives, and leave space for questions and emotions. It is important not to force a premature resolution of the situation through unilateral or coercive decisions⁵ (i.e., going off service does not mean I have to wrap up the existential crisis which is occurring.) A broader challenge is the grief and other emotions which accompany illness and death. I can neither prevent death nor grief, but I can offer my professional guidance and provide a supportive space for the patient and family to experience this transition. By acknowledging this, I center myself with the patient and family and we can work together toward a common goal of providing compassionate and ethical care.

Dr. Chase is associate professor, Department of Family and Community Medicine, University of California San Francisco; and co-chair, Ethics Committee, San Francisco General Hospital. Dr. Khawaja is assistant professor, Department of Internal Medicine, Baylor College of Medicine, Houston, and a member of the Ethics Committee of the Society of General Internal Medicine.

References

1. Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010 Nov 3;304(17):1946-7. doi: 10.1001/jama.2010.159.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 6th ed. New York: McGraw Hill Medical; 2006.

3. Baile WF, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. doi: 10.1634/theoncologist.5-4-302.

4. Chang DW, et al. Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments. JAMA Intern Med. 2021;181(6):786–794. doi: 10.1001/jamainternmed.2021.1000.

5. Sedig, L. What’s the role of autonomy in patient-and family-centered care when patients and family members don’t agree? AMA J Ethics. 2016;18(1):12-17. doi: 10.1001/journalofethics.2017.18.1.ecas2-1601.

Editor’s note: In this article, we present an archetypal ethics challenge in hospital medicine. The authors, members of the SHM’s Ethics Special Interest Group and clinical ethics consultants at their respective hospitals, will comment on the questions and practical approaches for hospitalists.

Ms. S, an 82-year-old woman with severe dementia, was initially hospitalized in the ICU with acute on chronic respiratory failure. Prior to admission, Ms. S lived with her daughter, who is her primary caregiver. Ms. S is able to say her daughter’s name, and answer “yes” and “no” to simple questions. She is bed bound, incontinent of urine and feces, and dependent on her daughter for all ADLs.

This admission, Ms. S has been re-intubated 4 times for recurrent respiratory failure. The nursing staff are distressed that she is suffering physically. Her daughter requests to continue all intensive, life-prolonging treatment including mechanical ventilation and artificial nutrition.

During sign out, your colleague remarks that his grandmother was in a similar situation and that his family chose to pursue comfort care. He questions whether Ms. S has any quality of life and asks if you think further intensive care is futile.

On your first day caring for Ms. S, you contact her primary care provider. Her PCP reports that Ms. S and her daughter completed an advance directive (AD) 10 years ago which documents a preference for all life prolonging treatment.
 

Question #1: What are the ethical challenges?

Dr. Chase: In caring for Ms. S, we face a common ethical challenge: how to respect the patient’s prior preferences (autonomy) when the currently requested treatments have diminishing benefits (beneficence) and escalating harms (non-maleficence). Life-prolonging care can have diminishing returns at the end of life. Ms. S’s loss of decision-making capacity adds a layer of complexity. Her AD was completed when she was able to consider decisions about her care, and she might make different decisions in her current state of health. Shared decision-making with a surrogate can be complicated by a surrogate’s anxiety with making life-altering decisions or their desire to avoid guilt or loneliness. Health care professionals face the limits of scientific knowledge in delivering accurate prognostic estimates, probabilities of recovery, and likelihood of benefit from interventions. In addition to the guideposts of ethical principles, some hospitals have policies which advise clinicians to avoid non-beneficial care.

Chase_Jack_CA_web.jpg

Such situations are emotionally intense and can trigger distress among patients, families, caregivers and health care professionals. Conscious and unconscious bias about a patient’s perceived quality of life undermines equity and can play a role in our recommendations for patients of advanced age, with cognitive impairment, and those who live with a disability.
 

Question #2: How might you meet the patient’s medical needs in line with her goals?

Dr. Khawaja: In order to provide care consistent with the patient’s goals, the first step is to clarify these goals with Ms. S’s surrogate decision-maker, her daughter. In a previously autonomous but presently incapacitated patient, the previously expressed preferences in the form of a written AD should be respected. However, the AD is only a set of preferences completed at a particular time, not medical orders. The clinician and surrogate must consider how to apply the AD to the current clinical circumstances. The clinician should verify that the clinical circumstances specified in the AD have been met and evaluate if the patient’s preferences have changed since she originally completed the AD.

Khawaja_Lubna_TX_web.jpg

Surrogates are asked to use a Substituted Judgement Standard (i.e., what would the patient choose in this situation if known). This may differ from what the surrogate wants. If not known, surrogates are asked to use the Best Interest Standard (i.e., what would bring the most net benefit to the patient by weighing benefits and risks of treatment options). I often ask the surrogate, “Tell us about your loved one.” Or, “Knowing your loved one, what do you think would be the most important for her right now?”¹

I would also caution against bias in judging quality of life in patients with dementia, and using the term “futility,” as these concepts are inherently subjective. In general, when a colleague raises the issue of futility, I begin by asking, “…futile to achieve what goal?” That can help clarify some of the disagreement as some goals can be accomplished while others cannot.

Finally, I work to include other members of our team in these discussions. The distress of nurses, social workers, and others are important to acknowledge, validate, and involve in the problem-solving process.
 

Question #3: If you were Ms. S’s hospitalist, what would you do?

Dr. Khawaja: As the hospitalist caring for Ms. S, I would use the “four boxes” model as a helpful, clinically relevant and systematic approach to managing ethical concerns.²

This “four boxes” model gives us a practical framework to address these ethical principles by asking questions in four domains.

Medical indications: What is the nature of her current illness, and is it reversible or not? What is the probability of success of treatment options like mechanical ventilation? Are there adverse effects of treatment?

Patient preferences: Since Ms. S lacks capacity, does her daughter understand the benefits and burdens of treatment? What are the goals of treatment? Prolonging life? Minimizing discomfort? Spending time with loved ones? What burdens would the patient be willing to endure to reach her goals?

Quality of life: What would the patient’s quality of life be with and without the treatments?

Contextual features: My priorities would be building a relationship of trust with Ms. S’s daughter – by educating her about her mother’s clinical status, addressing her concerns and questions, and supporting her as we work through patient-centered decisions about what is best for her mother. Honest communication is a must, even if it means acknowledging uncertainties about the course of disease and prognosis.

These are not easy decisions for surrogates to make. They should be given time to process information and to make what they believe are the best decisions for their loved ones. It is critical for clinicians to provide honest and complete clinical information and to avoid value judgments, bias, or unreasonable time pressure. While one-on-one conversations are central, I find that multidisciplinary meetings allow all stakeholders to ask and answer vital questions and ideally to reach consensus in treatment planning.

Dr. Chase: In caring for Ms. S, I would use a structured approach to discussions with her daughter, such as the “SPIKES” protocol.³ Using open ended questions, I would ask about the patient’s and her daughter’s goals, values, and fears and provide support about the responsibility for shared-decision making and the difficulty of uncertainty. Reflecting statements can help in confirming understanding and showing attention (e.g. “I hear that avoiding discomfort would be important to your mother.”)

I find it helpful to emphasize my commitment to honesty and non-abandonment (a common fear among patients and families). By offering to provide recommendations about both disease-directed and palliative, comfort-focused interventions, the patient’s daughter has an opportunity to engage voluntarily in discussion. When asked about care that may have marginal benefit, I suggest time-limited trials.⁴ I do not offer non-beneficial treatments and if asked about such treatments, I note the underlying motive and why the treatment is not feasible (“I see that you are hoping that your mother will live longer, but I am concerned that tube feeding will not help because…”), offer preferable alternatives, and leave space for questions and emotions. It is important not to force a premature resolution of the situation through unilateral or coercive decisions⁵ (i.e., going off service does not mean I have to wrap up the existential crisis which is occurring.) A broader challenge is the grief and other emotions which accompany illness and death. I can neither prevent death nor grief, but I can offer my professional guidance and provide a supportive space for the patient and family to experience this transition. By acknowledging this, I center myself with the patient and family and we can work together toward a common goal of providing compassionate and ethical care.

Dr. Chase is associate professor, Department of Family and Community Medicine, University of California San Francisco; and co-chair, Ethics Committee, San Francisco General Hospital. Dr. Khawaja is assistant professor, Department of Internal Medicine, Baylor College of Medicine, Houston, and a member of the Ethics Committee of the Society of General Internal Medicine.

References

1. Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010 Nov 3;304(17):1946-7. doi: 10.1001/jama.2010.159.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach to ethical decisions in clinical medicine. 6th ed. New York: McGraw Hill Medical; 2006.

3. Baile WF, et al. SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000;5(4):302–311. doi: 10.1634/theoncologist.5-4-302.

4. Chang DW, et al. Evaluation of time-limited trials among critically ill patients with advanced medical illnesses and reduction of nonbeneficial ICU treatments. JAMA Intern Med. 2021;181(6):786–794. doi: 10.1001/jamainternmed.2021.1000.

5. Sedig, L. What’s the role of autonomy in patient-and family-centered care when patients and family members don’t agree? AMA J Ethics. 2016;18(1):12-17. doi: 10.1001/journalofethics.2017.18.1.ecas2-1601.

The COVID-19 pandemic has given hospitalists a time to shine. Perhaps few people see – and value – this more than the hospital medicine administrators who work to support them behind the scenes.

“I’m very proud to have been given this opportunity to serve alongside these wonderful hospitalists,” said Elda Dede, FHM, hospital medicine division administrator at the University of Kentucky Healthcare in Lexington, Ky.

As with everything else in U.S. health care, the pandemic has affected hospital medicine administrators planning for 2021 and subsequent years in a big way. Despite all the challenges, some organizations are maintaining equilibrium, while others are even expanding. And intertwined through it all is a bright outlook and a distinct sense of team support.
 

Pandemic impacts on 2021 planning

Though the Texas Health Physicians Group (THPG) in Fort Worth is part of Texas Health Resources (THR), Ajay Kharbanda, MBA, SFHM, vice president of practice operations at THPG, said that each hospital within the THR system decides who that hospital will contract with for hospitalist services. Because the process is competitive and there’s no guarantee that THPG will get the contract each time, THPG has a large focus on the value they can bring to the hospitals they serve and the patients they care for.

“Having our physicians engaged with their hospital entity leaders was extremely important this year with planning around COVID because multiple hospitals had to create new COVID units,” said Mr. Kharbanda.

With the pressure of not enough volume early in the pandemic, other hospitalist groups were forced to cut back on staffing. “Within our health system, we made the cultural decision not to cancel any shifts or cut back on staffing because we didn’t want our hospitalists to be impacted negatively by things that were out of their control,” Mr. Kharbanda said.

This commitment to their hospitalists paid off when there was a surge of patients during the last quarter of 2020. “We were struggling to ensure there were adequate physicians available to take care of the patients in the hospital, but because we did the right thing by our physicians in the beginning, people did whatever it took to make sure there was enough staffing available for that increased patient volume,” Mr. Kharbanda said.

The first priority for University of Kentucky Healthcare is patient care, said Ms. Dede. Before the pandemic, the health system already had a two-layer jeopardy system in place to deal with scheduling needs in case a staff member couldn’t come in. “For the pandemic, we created six teams with an escalation and de-escalation pattern so that we could be ready to face whatever changes came in,” Ms. Dede said. Thankfully, the community wasn’t hit very hard by COVID-19, so the six new teams ended up being unnecessary, “but we were fully prepared, and everybody was ready to go.”

Making staffing plans amidst all the uncertainty surrounding the pandemic was a big challenge in planning for 2021, said Tiffani Panek, CLHM, SFHM, hospital medicine division administrator at Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, in Baltimore. “We don’t know what next week is going to look like, let alone what two or three months from now is going to look like, so we’ve really had to learn to be flexible,” she said. No longer is there just a Plan A that can be adjusted as needed; now there has to be a Plan B, C, and D as well.

Because the hospital medicine division’s budget is tied to the hospital, Ms. Panek said there hasn’t been a negative impact. “The hospital supports the program and continues to support the program, regardless of COVID,” she said. The health system as a whole did have to reduce benefits and freeze raises temporarily to ensure employees could keep their jobs. However, she said they have been fortunate in that their staff has been able to – and will continue to – stay in place.

As with others, volume fluctuation was an enormous hurdle in 2021 planning, said Larissa Smith, adult hospitalist and palliative care manager at The Salem Health Medical Group, Salem Health Hospitals and Clinics, in Salem, Ore. “It’s really highlighted the continued need for us to be agile in how we structure and operationalize our staffing,” Ms. Smith said. “Adapting to volume fluctuations has been our main focus.”

To prepare for both high and low patient volumes in 2021 and be able to adjust accordingly, The Salem Health Medical Group finalized in December 2020 what they call “team efficiency plans.” These plans consist of four primary areas: surge capacity, low census planning, right providers and right patient collaboration, and right team size.

Ms. Smith is working on the “right providers and right patient collaboration” component with the trauma and acute care, vascular, and general surgery teams to figure out the best ways to utilize hospitalists and specialists. “It’s been really great collaboration,” she said.
 

Administrative priorities during COVID-19

The pandemic hasn’t changed Ms. Panek’s administrative priorities, which include making sure her staff has whatever they need to do their jobs and that her providers have administrative support. “The work that’s had to be done to fulfill those priorities has changed in light of COVID though,” she said.

For example, she and her staff are all still off site, which she said has been challenging, especially given the lack of preparation they had. “In order to support my staff and to make sure they aren’t getting overwhelmed by being at home, that means my job looks a little bit different, but it doesn’t change my priorities,” said Ms. Panek.

By mid-summer, Ms. Dede said her main priority has been onboarding new team members, which she said is difficult with so many meetings being held virtually. “I’m not walking around the hallways with these people and having opportunities to get feedback about how their onboarding is going, so engaging so many new team members organically into the culture, the vision, the goals of our practice, is a challenge,” she said.

Taking advantage of opportunities for hospital medicine is another administrative priority for Ms. Dede. “For us to be able to take a seat at every possible table where decisions are being made, participate in shaping the strategic vision of the entire institution and be an active player in bringing that vision to life,” she said. “I feel like this is a crucial moment for hospitalists.”

Lean work, which includes the new team efficiency plans, is an administrative priority for Ms. Smith, as it is for the entire organization. “I would say that my biggest priority is just supporting our team,” Ms. Smith said. “We’ve been on a resiliency journey for a couple years.”

Their resiliency work involves periodic team training courtesy of Bryan Sexton, PhD, director of the Duke Center for Healthcare Safety and Quality. The goal of resiliency is to strengthen positive emotion, which enables a quicker recovery when difficulties occur. “I can’t imagine where we would be, this far into the pandemic, without that work,” said Ms. Smith. “I think it has really set us up to weather the storm, literally and figuratively.”

Ensuring the well-being of his provider group’s physicians is a high administrative priority for Mr. Kharbanda. Considering that the work they’ve always done is difficult, and the pandemic has been going on for such a long time, hospitalists are stretched thin. “We are bringing some additional resources to our providers that relate to taking care of themselves and helping them cope with the additional shifts,” Mr. Kharbanda said.
 

Going forward

The hospital medicine team at University of Kentucky Healthcare was already in the process of planning and adopting a new funds flow model, which increases the budget for HM, when the pandemic hit. “This is actually very good timing for us,” noted Ms. Dede. “We are currently working on building a new incentive model that maximizes engagement and academic productivity for our physicians, which in turn, will allow their careers to flourish and the involvement with enterprise leadership to increase.”

They had also planned to expand their teams and services before the pandemic, so in 2021, they’re hiring “an unprecedented number of hospitalists,” Ms. Dede said.

Mr. Kharbanda said that COVID has shown how much impact hospitalists can have on a hospital’s success, which has further highlighted their value. “Most of our programs are holding steady and we have some growth expected at some of our entities, so for those sites, we are hiring,” he said. Budget-wise, he expected to feel the pandemic’s impact for the first half of 2021, but for the second half, he hopes to return to normal.

Other than some low volumes in the spring, Salem Health has mostly maintained its typical capacities and funds. “Obviously, we don’t have control over external forces that impact health care, but we really try to home in on how we utilize our resources,” said Ms. Smith. “We’re a financially secure organization and I think our lean work really drives that.” The Salem Hospital is currently expanding a building tower to add another 150 beds, giving them more than 600 beds. “That will make us the largest hospital in Oregon,” Ms. Smith said.
 

Positive takeaways from the pandemic

Ms. Dede feels that hospital medicine has entered the health care spotlight with regard to hospitalists’ role in caring for patients during the pandemic. “Every challenge is an opportunity for growth and an opportunity to show that you know what you’re made of,” she said. “If there was ever doubt that the hospitalists are the beating heart of the hospital, this doubt is now gone. Hospitalists have, and will continue to, shoulder most of the care for COVID patients.”

The pandemic has also presented an opportunity at University of Kentucky Healthcare that helps accomplish both physician and hospital goals. “Hospital medicine is currently being asked to staff units and to participate in leadership committees, so this has been a great opportunity for growth for us,” Ms. Dede said.

The flexibility her team has shown has been a positive outcome for Ms. Panek. “You never really know what you’re going to be capable of doing until you have to do it,” she said. “I’m really proud of my group of administrative staff for how well that they’ve handled this considering it was supposed to be temporary. It’s really shown just how amazing the members of our team are and I think sometimes we take that for granted. COVID has made it so you don’t take things for granted anymore.”

Mr. Kharbanda sees how the pandemic has brought his hospitalist team together. Now, “it’s more like a family,” he said. “I think having the conversations around well-being and family safety were the real value as we learn to survive the pandemic. That was beautiful to see.”

The resiliency work her organization has done has helped Ms. Smith find plenty of positives in the face of the pandemic. “We are really resilient in health care and we can adapt quickly, but also safely,” she said.

Ms. Smith said the pandemic has also brought about changes for the better that will likely be permanent, like having time-saving virtual meetings and working from home. “We’ve put a lot of resources into physical structures and that takes away value from patients,” said Ms. Smith. “If we’re able to shift people in different roles to work from home, that just creates more future value for our community.”

Ms. Dede also sees the potential benefits that stem from people’s newfound comfort with video conferencing. “You can basically have grand rounds presenters from anywhere in the world,” she said. “You don’t have to fly them in, you don’t have to host them and have a whole program for a couple of days. They can talk to your people for an hour from the comfort of their home. I feel that we should take advantage of this too.”

Ms. Dede believes that expanding telehealth options and figuring out how hospitals can maximize that use is a priority right now. “Telehealth has been on the minds of so many hospital medicine practices, but there were still so many questions without answers about how to implement it,” she said. “During the pandemic, we were forced to find those solutions, but a lot of the barriers we are faced with have not been eliminated. I would recommend that groups keep their eyes open for new technological solutions that may empower your expansion into telehealth.”

The COVID-19 pandemic has given hospitalists a time to shine. Perhaps few people see – and value – this more than the hospital medicine administrators who work to support them behind the scenes.

“I’m very proud to have been given this opportunity to serve alongside these wonderful hospitalists,” said Elda Dede, FHM, hospital medicine division administrator at the University of Kentucky Healthcare in Lexington, Ky.

As with everything else in U.S. health care, the pandemic has affected hospital medicine administrators planning for 2021 and subsequent years in a big way. Despite all the challenges, some organizations are maintaining equilibrium, while others are even expanding. And intertwined through it all is a bright outlook and a distinct sense of team support.
 

Pandemic impacts on 2021 planning

Though the Texas Health Physicians Group (THPG) in Fort Worth is part of Texas Health Resources (THR), Ajay Kharbanda, MBA, SFHM, vice president of practice operations at THPG, said that each hospital within the THR system decides who that hospital will contract with for hospitalist services. Because the process is competitive and there’s no guarantee that THPG will get the contract each time, THPG has a large focus on the value they can bring to the hospitals they serve and the patients they care for.

“Having our physicians engaged with their hospital entity leaders was extremely important this year with planning around COVID because multiple hospitals had to create new COVID units,” said Mr. Kharbanda.

With the pressure of not enough volume early in the pandemic, other hospitalist groups were forced to cut back on staffing. “Within our health system, we made the cultural decision not to cancel any shifts or cut back on staffing because we didn’t want our hospitalists to be impacted negatively by things that were out of their control,” Mr. Kharbanda said.

This commitment to their hospitalists paid off when there was a surge of patients during the last quarter of 2020. “We were struggling to ensure there were adequate physicians available to take care of the patients in the hospital, but because we did the right thing by our physicians in the beginning, people did whatever it took to make sure there was enough staffing available for that increased patient volume,” Mr. Kharbanda said.

The first priority for University of Kentucky Healthcare is patient care, said Ms. Dede. Before the pandemic, the health system already had a two-layer jeopardy system in place to deal with scheduling needs in case a staff member couldn’t come in. “For the pandemic, we created six teams with an escalation and de-escalation pattern so that we could be ready to face whatever changes came in,” Ms. Dede said. Thankfully, the community wasn’t hit very hard by COVID-19, so the six new teams ended up being unnecessary, “but we were fully prepared, and everybody was ready to go.”

Making staffing plans amidst all the uncertainty surrounding the pandemic was a big challenge in planning for 2021, said Tiffani Panek, CLHM, SFHM, hospital medicine division administrator at Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, in Baltimore. “We don’t know what next week is going to look like, let alone what two or three months from now is going to look like, so we’ve really had to learn to be flexible,” she said. No longer is there just a Plan A that can be adjusted as needed; now there has to be a Plan B, C, and D as well.

Because the hospital medicine division’s budget is tied to the hospital, Ms. Panek said there hasn’t been a negative impact. “The hospital supports the program and continues to support the program, regardless of COVID,” she said. The health system as a whole did have to reduce benefits and freeze raises temporarily to ensure employees could keep their jobs. However, she said they have been fortunate in that their staff has been able to – and will continue to – stay in place.

As with others, volume fluctuation was an enormous hurdle in 2021 planning, said Larissa Smith, adult hospitalist and palliative care manager at The Salem Health Medical Group, Salem Health Hospitals and Clinics, in Salem, Ore. “It’s really highlighted the continued need for us to be agile in how we structure and operationalize our staffing,” Ms. Smith said. “Adapting to volume fluctuations has been our main focus.”

To prepare for both high and low patient volumes in 2021 and be able to adjust accordingly, The Salem Health Medical Group finalized in December 2020 what they call “team efficiency plans.” These plans consist of four primary areas: surge capacity, low census planning, right providers and right patient collaboration, and right team size.

Ms. Smith is working on the “right providers and right patient collaboration” component with the trauma and acute care, vascular, and general surgery teams to figure out the best ways to utilize hospitalists and specialists. “It’s been really great collaboration,” she said.
 

Administrative priorities during COVID-19

The pandemic hasn’t changed Ms. Panek’s administrative priorities, which include making sure her staff has whatever they need to do their jobs and that her providers have administrative support. “The work that’s had to be done to fulfill those priorities has changed in light of COVID though,” she said.

For example, she and her staff are all still off site, which she said has been challenging, especially given the lack of preparation they had. “In order to support my staff and to make sure they aren’t getting overwhelmed by being at home, that means my job looks a little bit different, but it doesn’t change my priorities,” said Ms. Panek.

By mid-summer, Ms. Dede said her main priority has been onboarding new team members, which she said is difficult with so many meetings being held virtually. “I’m not walking around the hallways with these people and having opportunities to get feedback about how their onboarding is going, so engaging so many new team members organically into the culture, the vision, the goals of our practice, is a challenge,” she said.

Taking advantage of opportunities for hospital medicine is another administrative priority for Ms. Dede. “For us to be able to take a seat at every possible table where decisions are being made, participate in shaping the strategic vision of the entire institution and be an active player in bringing that vision to life,” she said. “I feel like this is a crucial moment for hospitalists.”

Lean work, which includes the new team efficiency plans, is an administrative priority for Ms. Smith, as it is for the entire organization. “I would say that my biggest priority is just supporting our team,” Ms. Smith said. “We’ve been on a resiliency journey for a couple years.”

Their resiliency work involves periodic team training courtesy of Bryan Sexton, PhD, director of the Duke Center for Healthcare Safety and Quality. The goal of resiliency is to strengthen positive emotion, which enables a quicker recovery when difficulties occur. “I can’t imagine where we would be, this far into the pandemic, without that work,” said Ms. Smith. “I think it has really set us up to weather the storm, literally and figuratively.”

Ensuring the well-being of his provider group’s physicians is a high administrative priority for Mr. Kharbanda. Considering that the work they’ve always done is difficult, and the pandemic has been going on for such a long time, hospitalists are stretched thin. “We are bringing some additional resources to our providers that relate to taking care of themselves and helping them cope with the additional shifts,” Mr. Kharbanda said.
 

Going forward

The hospital medicine team at University of Kentucky Healthcare was already in the process of planning and adopting a new funds flow model, which increases the budget for HM, when the pandemic hit. “This is actually very good timing for us,” noted Ms. Dede. “We are currently working on building a new incentive model that maximizes engagement and academic productivity for our physicians, which in turn, will allow their careers to flourish and the involvement with enterprise leadership to increase.”

They had also planned to expand their teams and services before the pandemic, so in 2021, they’re hiring “an unprecedented number of hospitalists,” Ms. Dede said.

Mr. Kharbanda said that COVID has shown how much impact hospitalists can have on a hospital’s success, which has further highlighted their value. “Most of our programs are holding steady and we have some growth expected at some of our entities, so for those sites, we are hiring,” he said. Budget-wise, he expected to feel the pandemic’s impact for the first half of 2021, but for the second half, he hopes to return to normal.

Other than some low volumes in the spring, Salem Health has mostly maintained its typical capacities and funds. “Obviously, we don’t have control over external forces that impact health care, but we really try to home in on how we utilize our resources,” said Ms. Smith. “We’re a financially secure organization and I think our lean work really drives that.” The Salem Hospital is currently expanding a building tower to add another 150 beds, giving them more than 600 beds. “That will make us the largest hospital in Oregon,” Ms. Smith said.
 

Positive takeaways from the pandemic

Ms. Dede feels that hospital medicine has entered the health care spotlight with regard to hospitalists’ role in caring for patients during the pandemic. “Every challenge is an opportunity for growth and an opportunity to show that you know what you’re made of,” she said. “If there was ever doubt that the hospitalists are the beating heart of the hospital, this doubt is now gone. Hospitalists have, and will continue to, shoulder most of the care for COVID patients.”

The pandemic has also presented an opportunity at University of Kentucky Healthcare that helps accomplish both physician and hospital goals. “Hospital medicine is currently being asked to staff units and to participate in leadership committees, so this has been a great opportunity for growth for us,” Ms. Dede said.

The flexibility her team has shown has been a positive outcome for Ms. Panek. “You never really know what you’re going to be capable of doing until you have to do it,” she said. “I’m really proud of my group of administrative staff for how well that they’ve handled this considering it was supposed to be temporary. It’s really shown just how amazing the members of our team are and I think sometimes we take that for granted. COVID has made it so you don’t take things for granted anymore.”

Mr. Kharbanda sees how the pandemic has brought his hospitalist team together. Now, “it’s more like a family,” he said. “I think having the conversations around well-being and family safety were the real value as we learn to survive the pandemic. That was beautiful to see.”

The resiliency work her organization has done has helped Ms. Smith find plenty of positives in the face of the pandemic. “We are really resilient in health care and we can adapt quickly, but also safely,” she said.

Ms. Smith said the pandemic has also brought about changes for the better that will likely be permanent, like having time-saving virtual meetings and working from home. “We’ve put a lot of resources into physical structures and that takes away value from patients,” said Ms. Smith. “If we’re able to shift people in different roles to work from home, that just creates more future value for our community.”

Ms. Dede also sees the potential benefits that stem from people’s newfound comfort with video conferencing. “You can basically have grand rounds presenters from anywhere in the world,” she said. “You don’t have to fly them in, you don’t have to host them and have a whole program for a couple of days. They can talk to your people for an hour from the comfort of their home. I feel that we should take advantage of this too.”

Ms. Dede believes that expanding telehealth options and figuring out how hospitals can maximize that use is a priority right now. “Telehealth has been on the minds of so many hospital medicine practices, but there were still so many questions without answers about how to implement it,” she said. “During the pandemic, we were forced to find those solutions, but a lot of the barriers we are faced with have not been eliminated. I would recommend that groups keep their eyes open for new technological solutions that may empower your expansion into telehealth.”

The COVID-19 pandemic has given hospitalists a time to shine. Perhaps few people see – and value – this more than the hospital medicine administrators who work to support them behind the scenes.

“I’m very proud to have been given this opportunity to serve alongside these wonderful hospitalists,” said Elda Dede, FHM, hospital medicine division administrator at the University of Kentucky Healthcare in Lexington, Ky.

As with everything else in U.S. health care, the pandemic has affected hospital medicine administrators planning for 2021 and subsequent years in a big way. Despite all the challenges, some organizations are maintaining equilibrium, while others are even expanding. And intertwined through it all is a bright outlook and a distinct sense of team support.
 

Pandemic impacts on 2021 planning

Though the Texas Health Physicians Group (THPG) in Fort Worth is part of Texas Health Resources (THR), Ajay Kharbanda, MBA, SFHM, vice president of practice operations at THPG, said that each hospital within the THR system decides who that hospital will contract with for hospitalist services. Because the process is competitive and there’s no guarantee that THPG will get the contract each time, THPG has a large focus on the value they can bring to the hospitals they serve and the patients they care for.

“Having our physicians engaged with their hospital entity leaders was extremely important this year with planning around COVID because multiple hospitals had to create new COVID units,” said Mr. Kharbanda.

With the pressure of not enough volume early in the pandemic, other hospitalist groups were forced to cut back on staffing. “Within our health system, we made the cultural decision not to cancel any shifts or cut back on staffing because we didn’t want our hospitalists to be impacted negatively by things that were out of their control,” Mr. Kharbanda said.

This commitment to their hospitalists paid off when there was a surge of patients during the last quarter of 2020. “We were struggling to ensure there were adequate physicians available to take care of the patients in the hospital, but because we did the right thing by our physicians in the beginning, people did whatever it took to make sure there was enough staffing available for that increased patient volume,” Mr. Kharbanda said.

The first priority for University of Kentucky Healthcare is patient care, said Ms. Dede. Before the pandemic, the health system already had a two-layer jeopardy system in place to deal with scheduling needs in case a staff member couldn’t come in. “For the pandemic, we created six teams with an escalation and de-escalation pattern so that we could be ready to face whatever changes came in,” Ms. Dede said. Thankfully, the community wasn’t hit very hard by COVID-19, so the six new teams ended up being unnecessary, “but we were fully prepared, and everybody was ready to go.”

Making staffing plans amidst all the uncertainty surrounding the pandemic was a big challenge in planning for 2021, said Tiffani Panek, CLHM, SFHM, hospital medicine division administrator at Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, in Baltimore. “We don’t know what next week is going to look like, let alone what two or three months from now is going to look like, so we’ve really had to learn to be flexible,” she said. No longer is there just a Plan A that can be adjusted as needed; now there has to be a Plan B, C, and D as well.

Because the hospital medicine division’s budget is tied to the hospital, Ms. Panek said there hasn’t been a negative impact. “The hospital supports the program and continues to support the program, regardless of COVID,” she said. The health system as a whole did have to reduce benefits and freeze raises temporarily to ensure employees could keep their jobs. However, she said they have been fortunate in that their staff has been able to – and will continue to – stay in place.

As with others, volume fluctuation was an enormous hurdle in 2021 planning, said Larissa Smith, adult hospitalist and palliative care manager at The Salem Health Medical Group, Salem Health Hospitals and Clinics, in Salem, Ore. “It’s really highlighted the continued need for us to be agile in how we structure and operationalize our staffing,” Ms. Smith said. “Adapting to volume fluctuations has been our main focus.”

To prepare for both high and low patient volumes in 2021 and be able to adjust accordingly, The Salem Health Medical Group finalized in December 2020 what they call “team efficiency plans.” These plans consist of four primary areas: surge capacity, low census planning, right providers and right patient collaboration, and right team size.

Ms. Smith is working on the “right providers and right patient collaboration” component with the trauma and acute care, vascular, and general surgery teams to figure out the best ways to utilize hospitalists and specialists. “It’s been really great collaboration,” she said.
 

Administrative priorities during COVID-19

The pandemic hasn’t changed Ms. Panek’s administrative priorities, which include making sure her staff has whatever they need to do their jobs and that her providers have administrative support. “The work that’s had to be done to fulfill those priorities has changed in light of COVID though,” she said.

For example, she and her staff are all still off site, which she said has been challenging, especially given the lack of preparation they had. “In order to support my staff and to make sure they aren’t getting overwhelmed by being at home, that means my job looks a little bit different, but it doesn’t change my priorities,” said Ms. Panek.

By mid-summer, Ms. Dede said her main priority has been onboarding new team members, which she said is difficult with so many meetings being held virtually. “I’m not walking around the hallways with these people and having opportunities to get feedback about how their onboarding is going, so engaging so many new team members organically into the culture, the vision, the goals of our practice, is a challenge,” she said.

Taking advantage of opportunities for hospital medicine is another administrative priority for Ms. Dede. “For us to be able to take a seat at every possible table where decisions are being made, participate in shaping the strategic vision of the entire institution and be an active player in bringing that vision to life,” she said. “I feel like this is a crucial moment for hospitalists.”

Lean work, which includes the new team efficiency plans, is an administrative priority for Ms. Smith, as it is for the entire organization. “I would say that my biggest priority is just supporting our team,” Ms. Smith said. “We’ve been on a resiliency journey for a couple years.”

Their resiliency work involves periodic team training courtesy of Bryan Sexton, PhD, director of the Duke Center for Healthcare Safety and Quality. The goal of resiliency is to strengthen positive emotion, which enables a quicker recovery when difficulties occur. “I can’t imagine where we would be, this far into the pandemic, without that work,” said Ms. Smith. “I think it has really set us up to weather the storm, literally and figuratively.”

Ensuring the well-being of his provider group’s physicians is a high administrative priority for Mr. Kharbanda. Considering that the work they’ve always done is difficult, and the pandemic has been going on for such a long time, hospitalists are stretched thin. “We are bringing some additional resources to our providers that relate to taking care of themselves and helping them cope with the additional shifts,” Mr. Kharbanda said.
 

Going forward

The hospital medicine team at University of Kentucky Healthcare was already in the process of planning and adopting a new funds flow model, which increases the budget for HM, when the pandemic hit. “This is actually very good timing for us,” noted Ms. Dede. “We are currently working on building a new incentive model that maximizes engagement and academic productivity for our physicians, which in turn, will allow their careers to flourish and the involvement with enterprise leadership to increase.”

They had also planned to expand their teams and services before the pandemic, so in 2021, they’re hiring “an unprecedented number of hospitalists,” Ms. Dede said.

Mr. Kharbanda said that COVID has shown how much impact hospitalists can have on a hospital’s success, which has further highlighted their value. “Most of our programs are holding steady and we have some growth expected at some of our entities, so for those sites, we are hiring,” he said. Budget-wise, he expected to feel the pandemic’s impact for the first half of 2021, but for the second half, he hopes to return to normal.

Other than some low volumes in the spring, Salem Health has mostly maintained its typical capacities and funds. “Obviously, we don’t have control over external forces that impact health care, but we really try to home in on how we utilize our resources,” said Ms. Smith. “We’re a financially secure organization and I think our lean work really drives that.” The Salem Hospital is currently expanding a building tower to add another 150 beds, giving them more than 600 beds. “That will make us the largest hospital in Oregon,” Ms. Smith said.
 

Positive takeaways from the pandemic

Ms. Dede feels that hospital medicine has entered the health care spotlight with regard to hospitalists’ role in caring for patients during the pandemic. “Every challenge is an opportunity for growth and an opportunity to show that you know what you’re made of,” she said. “If there was ever doubt that the hospitalists are the beating heart of the hospital, this doubt is now gone. Hospitalists have, and will continue to, shoulder most of the care for COVID patients.”

The pandemic has also presented an opportunity at University of Kentucky Healthcare that helps accomplish both physician and hospital goals. “Hospital medicine is currently being asked to staff units and to participate in leadership committees, so this has been a great opportunity for growth for us,” Ms. Dede said.

The flexibility her team has shown has been a positive outcome for Ms. Panek. “You never really know what you’re going to be capable of doing until you have to do it,” she said. “I’m really proud of my group of administrative staff for how well that they’ve handled this considering it was supposed to be temporary. It’s really shown just how amazing the members of our team are and I think sometimes we take that for granted. COVID has made it so you don’t take things for granted anymore.”

Mr. Kharbanda sees how the pandemic has brought his hospitalist team together. Now, “it’s more like a family,” he said. “I think having the conversations around well-being and family safety were the real value as we learn to survive the pandemic. That was beautiful to see.”

The resiliency work her organization has done has helped Ms. Smith find plenty of positives in the face of the pandemic. “We are really resilient in health care and we can adapt quickly, but also safely,” she said.

Ms. Smith said the pandemic has also brought about changes for the better that will likely be permanent, like having time-saving virtual meetings and working from home. “We’ve put a lot of resources into physical structures and that takes away value from patients,” said Ms. Smith. “If we’re able to shift people in different roles to work from home, that just creates more future value for our community.”

Ms. Dede also sees the potential benefits that stem from people’s newfound comfort with video conferencing. “You can basically have grand rounds presenters from anywhere in the world,” she said. “You don’t have to fly them in, you don’t have to host them and have a whole program for a couple of days. They can talk to your people for an hour from the comfort of their home. I feel that we should take advantage of this too.”

Ms. Dede believes that expanding telehealth options and figuring out how hospitals can maximize that use is a priority right now. “Telehealth has been on the minds of so many hospital medicine practices, but there were still so many questions without answers about how to implement it,” she said. “During the pandemic, we were forced to find those solutions, but a lot of the barriers we are faced with have not been eliminated. I would recommend that groups keep their eyes open for new technological solutions that may empower your expansion into telehealth.”