Perspectives

Congratulations! You’re about to start your first year as a hospitalist, and in many cases your first real job. Hospital medicine is an incredibly rewarding subspecialty, but the progression from resident to attending physician can be daunting. To facilitate this transition, we present FIND (Familiarity, Identity, Network, and Direction) – a novel, sequential framework for success as a first-year hospitalist. For each component, we provide a narrative overview and a summary bullet point for quick reference.

Familiarity

• Lay the foundation: Learn the ins and outs of your job, EMR, and team.

Familiarize yourself with your surroundings. Know where your patients are located, where you can document, where to find equipment for procedures, and how to reach information technology. Proactively set up the electronic medical record on your home computer and phone. Make sure to review your responsibilities, including your call schedule, your shifts, your assigned patient panel, when you can leave campus, and how people should contact you. Also, others should know your expectations of them, especially if you are working with trainees.

Maintain a file with all of your orientation materials, including phone numbers and emails of key personnel. Know who your people are – who can access your calendar, who you can call with a clinical question or to escalate care, who can assist you with billing, and who helps with the throughput of your patients in the hospital. Take time to review your benefits, including parental leave, insurance coverage, retirement planning, vacation time, and ancillary services like laundry for your white coat. Familiarizing yourself with these basics will provide comfort and lay the foundation for your first year.
 

Identity

• Perform self-reflection: Overcome imposter syndrome and invest in hobbies.

One of the fundamental realizations that will occur with your first hospitalist job is that you are the attending. You walk in with a vision of your first job; be prepared to be surprised. You have earned the privilege of deciding on patient plans, and you are no longer obligated to staff with a senior physician. This is both empowering and terrifying. In a way, it may oddly remind you of intern year. A new hospital, new EMR, new colleagues, and imposter syndrome will trick you into doubting your decisions.

How to battle it? Positive thinking. You do know the basics of inpatient medicine and you do have a support system to cheer you on. As part of imposter syndrome, you may feel pressured to focus solely on work. Yet, your first job as a hospitalist is finally an amazing opportunity to focus on you. What hobbies have you been neglecting: cooking, photography, reading, more time with family, a new pet? You have the power to schedule your off-weeks. Are you interested in academics? Reserve a portion of your time off to explore scholarship opportunities at your institution. Your first job as a hospitalist is a chance to develop your identity, both as a physician and as an individual.
 

Network

• Engage your support system: Communicate with nursing, administration, colleagues.

Networking, or building a web of mutually beneficial professional relationships, is imperative for long-term career success. Hospitalists should focus on developing their network across multiple departments, such as nursing, subspecialties, medical education, and hospital administration. Curating a broad network will increase your visibility within your organization, showcase your unique services, and demonstrate your value.

To make networking encounters impactful, express interest, actively listen, ask relevant questions, and seek areas of mutual benefit. It’s equally important to cultivate these new relationships after the initial encounter and to demonstrate how your skill set will aid colleagues in achieving their professional goals. Over time, as you establish your niche, deliberate networking with those who share similar interests can lead to a wealth of new experiences and opportunities. Intentionally mastering networking early in your career provides insight into different aspects of the hospital system, new perspectives on ideas, and access to valuable guidance from other professionals. Engaging in networking to establish your support system is an essential step towards success as a first-year hospitalist.
 

Direction

• Visualize your path: Find a mentor and develop a mission statement and career plan.

Once you’re familiar with your work environment, confident in your identity, and acquainted with your support network, you’re ready for the final step – direction. Hospital medicine offers many professional avenues and clarifying your career path is challenging when attempted alone. A mentor is the necessary catalyst to find direction and purpose.

Selecting and engaging with a mentor will bolster your professional advancement, academic productivity, and most importantly, career satisfaction.¹ At its best, mentorship is a symbiotic relationship. Your mentor should inspire you, challenge you, and support your growth and emotional well-being. In turn, as the mentee, you should be proactive, establish expectations, and take responsibility for maintaining communication to ensure a successful relationship. As your career takes shape over time, you may require a mentorship team to fulfill your unique needs.

When you’ve established a relationship with your mentor, take time to develop 1-year and 5-year plans. Your 1-year plan should focus on a few “quick wins,” often projects or opportunities at your home institution. Small victories in your first year will boost your confidence, motivation, and sense of control. Your 5-year plan should delineate the steps necessary to make your first major career transition, such as from instructor to assistant professor. Working with your mentor to draft a career mission statement is a useful first step in this process. Beginning with the end in mind, will help you visualize your direction.²

We hope that the FIND framework will help you find your path to success as a first-year hospitalist.

Dr. Nelson is a hospitalist and instructor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, both in Boston. Dr. Ashford is assistant professor and program director, department of internal medicine/pediatrics, at the University of Nebraska Medical Center, Omaha. Dr. Rawal is clinical assistant professor of medicine at the University of Pittsburgh Medical Center. Dr. Crecelius is assistant professor of clinical medicine at Indiana University, Indianapolis. This article is sponsored by the SHM Physicians in Training committee, which submits quarterly content to the Hospitalist on topics relevant to trainees and early -career hospitalists.

References

1. Zerzan JT et al. Making the most of mentors: a guide for mentees. Acad Med. 2009;84:140-4. doi: 10.1097/ACM.0b013e3181906e8f.

2. Covey F. The seven habits of highly effective people. 25th anniversary edition. New York: Simon and Schuster, 2013.




 

Congratulations! You’re about to start your first year as a hospitalist, and in many cases your first real job. Hospital medicine is an incredibly rewarding subspecialty, but the progression from resident to attending physician can be daunting. To facilitate this transition, we present FIND (Familiarity, Identity, Network, and Direction) – a novel, sequential framework for success as a first-year hospitalist. For each component, we provide a narrative overview and a summary bullet point for quick reference.

Familiarity

• Lay the foundation: Learn the ins and outs of your job, EMR, and team.

Familiarize yourself with your surroundings. Know where your patients are located, where you can document, where to find equipment for procedures, and how to reach information technology. Proactively set up the electronic medical record on your home computer and phone. Make sure to review your responsibilities, including your call schedule, your shifts, your assigned patient panel, when you can leave campus, and how people should contact you. Also, others should know your expectations of them, especially if you are working with trainees.

Maintain a file with all of your orientation materials, including phone numbers and emails of key personnel. Know who your people are – who can access your calendar, who you can call with a clinical question or to escalate care, who can assist you with billing, and who helps with the throughput of your patients in the hospital. Take time to review your benefits, including parental leave, insurance coverage, retirement planning, vacation time, and ancillary services like laundry for your white coat. Familiarizing yourself with these basics will provide comfort and lay the foundation for your first year.
 

Identity

• Perform self-reflection: Overcome imposter syndrome and invest in hobbies.

One of the fundamental realizations that will occur with your first hospitalist job is that you are the attending. You walk in with a vision of your first job; be prepared to be surprised. You have earned the privilege of deciding on patient plans, and you are no longer obligated to staff with a senior physician. This is both empowering and terrifying. In a way, it may oddly remind you of intern year. A new hospital, new EMR, new colleagues, and imposter syndrome will trick you into doubting your decisions.

How to battle it? Positive thinking. You do know the basics of inpatient medicine and you do have a support system to cheer you on. As part of imposter syndrome, you may feel pressured to focus solely on work. Yet, your first job as a hospitalist is finally an amazing opportunity to focus on you. What hobbies have you been neglecting: cooking, photography, reading, more time with family, a new pet? You have the power to schedule your off-weeks. Are you interested in academics? Reserve a portion of your time off to explore scholarship opportunities at your institution. Your first job as a hospitalist is a chance to develop your identity, both as a physician and as an individual.
 

Network

• Engage your support system: Communicate with nursing, administration, colleagues.

Networking, or building a web of mutually beneficial professional relationships, is imperative for long-term career success. Hospitalists should focus on developing their network across multiple departments, such as nursing, subspecialties, medical education, and hospital administration. Curating a broad network will increase your visibility within your organization, showcase your unique services, and demonstrate your value.

To make networking encounters impactful, express interest, actively listen, ask relevant questions, and seek areas of mutual benefit. It’s equally important to cultivate these new relationships after the initial encounter and to demonstrate how your skill set will aid colleagues in achieving their professional goals. Over time, as you establish your niche, deliberate networking with those who share similar interests can lead to a wealth of new experiences and opportunities. Intentionally mastering networking early in your career provides insight into different aspects of the hospital system, new perspectives on ideas, and access to valuable guidance from other professionals. Engaging in networking to establish your support system is an essential step towards success as a first-year hospitalist.
 

Direction

• Visualize your path: Find a mentor and develop a mission statement and career plan.

Once you’re familiar with your work environment, confident in your identity, and acquainted with your support network, you’re ready for the final step – direction. Hospital medicine offers many professional avenues and clarifying your career path is challenging when attempted alone. A mentor is the necessary catalyst to find direction and purpose.

Selecting and engaging with a mentor will bolster your professional advancement, academic productivity, and most importantly, career satisfaction.¹ At its best, mentorship is a symbiotic relationship. Your mentor should inspire you, challenge you, and support your growth and emotional well-being. In turn, as the mentee, you should be proactive, establish expectations, and take responsibility for maintaining communication to ensure a successful relationship. As your career takes shape over time, you may require a mentorship team to fulfill your unique needs.

When you’ve established a relationship with your mentor, take time to develop 1-year and 5-year plans. Your 1-year plan should focus on a few “quick wins,” often projects or opportunities at your home institution. Small victories in your first year will boost your confidence, motivation, and sense of control. Your 5-year plan should delineate the steps necessary to make your first major career transition, such as from instructor to assistant professor. Working with your mentor to draft a career mission statement is a useful first step in this process. Beginning with the end in mind, will help you visualize your direction.²

We hope that the FIND framework will help you find your path to success as a first-year hospitalist.

Dr. Nelson is a hospitalist and instructor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, both in Boston. Dr. Ashford is assistant professor and program director, department of internal medicine/pediatrics, at the University of Nebraska Medical Center, Omaha. Dr. Rawal is clinical assistant professor of medicine at the University of Pittsburgh Medical Center. Dr. Crecelius is assistant professor of clinical medicine at Indiana University, Indianapolis. This article is sponsored by the SHM Physicians in Training committee, which submits quarterly content to the Hospitalist on topics relevant to trainees and early -career hospitalists.

References

1. Zerzan JT et al. Making the most of mentors: a guide for mentees. Acad Med. 2009;84:140-4. doi: 10.1097/ACM.0b013e3181906e8f.

2. Covey F. The seven habits of highly effective people. 25th anniversary edition. New York: Simon and Schuster, 2013.




 

Congratulations! You’re about to start your first year as a hospitalist, and in many cases your first real job. Hospital medicine is an incredibly rewarding subspecialty, but the progression from resident to attending physician can be daunting. To facilitate this transition, we present FIND (Familiarity, Identity, Network, and Direction) – a novel, sequential framework for success as a first-year hospitalist. For each component, we provide a narrative overview and a summary bullet point for quick reference.

Familiarity

• Lay the foundation: Learn the ins and outs of your job, EMR, and team.

Familiarize yourself with your surroundings. Know where your patients are located, where you can document, where to find equipment for procedures, and how to reach information technology. Proactively set up the electronic medical record on your home computer and phone. Make sure to review your responsibilities, including your call schedule, your shifts, your assigned patient panel, when you can leave campus, and how people should contact you. Also, others should know your expectations of them, especially if you are working with trainees.

Maintain a file with all of your orientation materials, including phone numbers and emails of key personnel. Know who your people are – who can access your calendar, who you can call with a clinical question or to escalate care, who can assist you with billing, and who helps with the throughput of your patients in the hospital. Take time to review your benefits, including parental leave, insurance coverage, retirement planning, vacation time, and ancillary services like laundry for your white coat. Familiarizing yourself with these basics will provide comfort and lay the foundation for your first year.
 

Identity

• Perform self-reflection: Overcome imposter syndrome and invest in hobbies.

One of the fundamental realizations that will occur with your first hospitalist job is that you are the attending. You walk in with a vision of your first job; be prepared to be surprised. You have earned the privilege of deciding on patient plans, and you are no longer obligated to staff with a senior physician. This is both empowering and terrifying. In a way, it may oddly remind you of intern year. A new hospital, new EMR, new colleagues, and imposter syndrome will trick you into doubting your decisions.

How to battle it? Positive thinking. You do know the basics of inpatient medicine and you do have a support system to cheer you on. As part of imposter syndrome, you may feel pressured to focus solely on work. Yet, your first job as a hospitalist is finally an amazing opportunity to focus on you. What hobbies have you been neglecting: cooking, photography, reading, more time with family, a new pet? You have the power to schedule your off-weeks. Are you interested in academics? Reserve a portion of your time off to explore scholarship opportunities at your institution. Your first job as a hospitalist is a chance to develop your identity, both as a physician and as an individual.
 

Network

• Engage your support system: Communicate with nursing, administration, colleagues.

Networking, or building a web of mutually beneficial professional relationships, is imperative for long-term career success. Hospitalists should focus on developing their network across multiple departments, such as nursing, subspecialties, medical education, and hospital administration. Curating a broad network will increase your visibility within your organization, showcase your unique services, and demonstrate your value.

To make networking encounters impactful, express interest, actively listen, ask relevant questions, and seek areas of mutual benefit. It’s equally important to cultivate these new relationships after the initial encounter and to demonstrate how your skill set will aid colleagues in achieving their professional goals. Over time, as you establish your niche, deliberate networking with those who share similar interests can lead to a wealth of new experiences and opportunities. Intentionally mastering networking early in your career provides insight into different aspects of the hospital system, new perspectives on ideas, and access to valuable guidance from other professionals. Engaging in networking to establish your support system is an essential step towards success as a first-year hospitalist.
 

Direction

• Visualize your path: Find a mentor and develop a mission statement and career plan.

Once you’re familiar with your work environment, confident in your identity, and acquainted with your support network, you’re ready for the final step – direction. Hospital medicine offers many professional avenues and clarifying your career path is challenging when attempted alone. A mentor is the necessary catalyst to find direction and purpose.

Selecting and engaging with a mentor will bolster your professional advancement, academic productivity, and most importantly, career satisfaction.¹ At its best, mentorship is a symbiotic relationship. Your mentor should inspire you, challenge you, and support your growth and emotional well-being. In turn, as the mentee, you should be proactive, establish expectations, and take responsibility for maintaining communication to ensure a successful relationship. As your career takes shape over time, you may require a mentorship team to fulfill your unique needs.

When you’ve established a relationship with your mentor, take time to develop 1-year and 5-year plans. Your 1-year plan should focus on a few “quick wins,” often projects or opportunities at your home institution. Small victories in your first year will boost your confidence, motivation, and sense of control. Your 5-year plan should delineate the steps necessary to make your first major career transition, such as from instructor to assistant professor. Working with your mentor to draft a career mission statement is a useful first step in this process. Beginning with the end in mind, will help you visualize your direction.²

We hope that the FIND framework will help you find your path to success as a first-year hospitalist.

Dr. Nelson is a hospitalist and instructor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, both in Boston. Dr. Ashford is assistant professor and program director, department of internal medicine/pediatrics, at the University of Nebraska Medical Center, Omaha. Dr. Rawal is clinical assistant professor of medicine at the University of Pittsburgh Medical Center. Dr. Crecelius is assistant professor of clinical medicine at Indiana University, Indianapolis. This article is sponsored by the SHM Physicians in Training committee, which submits quarterly content to the Hospitalist on topics relevant to trainees and early -career hospitalists.

References

1. Zerzan JT et al. Making the most of mentors: a guide for mentees. Acad Med. 2009;84:140-4. doi: 10.1097/ACM.0b013e3181906e8f.

2. Covey F. The seven habits of highly effective people. 25th anniversary edition. New York: Simon and Schuster, 2013.




 

For many physicians and other professionals, aspirations of crafting a work of fiction are not uncommon — and with good reason. We are, after all, a generally well-disciplined bunch capable of completing complex tasks, and there is certainly no shortage of excitement and drama in medicine and surgery — ample fodder for thrilling stories. Nonetheless, writing a novel is a major commitment, and it requires persistence, patience, and dedicated time, especially for one with a busy medical career.

Getting started is not easy. Writing workshops are helpful, and in my case, I tried to mentor with some of the best. Before writing my novel, I attended workshops for aspiring novelists, given by noted physician authors Tess Gerritsen (Body Double, The Surgeon) and the late Michael Palmer (The Society, The Fifth Vial).

Writers are often advised to “write about what you know.” In my case, I combined my knowledge of medicine and my experience with the thoroughbred racing world to craft a thriller that one reviewer described as “Dick Francis meets Robin Cook.” For those who have never read the Dick Francis series, he was a renowned crime writer whose novels centered on horse racing in England. Having been an avid reader of both authors, that comparison was the ultimate compliment.

So against that backdrop, here is my distillation of 10 key points on the craft of writing a great thriller, based on my own experience in writing the novel Shedrow, along with some shared wisdom from a few legendary writers.

1. Start with the big “what if.” Any great story starts with that simple “what if” question. What if a series of high-profile executives in the managed care industry are serially murdered (Michael Palmer’s The Society)? What if a multimillion-dollar stallion dies suddenly under very mysterious circumstances on a supposedly secure farm in Kentucky (Dean DeLuke’s Shedrow)?

2. Put a MacGuffin to work in your story. Popularized by Alfred Hitchcock, the MacGuffin is that essential plot element that drives virtually all characters in the story, although it may be rather vague and meaningless to the story itself. In the iconic movie Pulp Fiction, the MacGuffin is the briefcase — everyone wants it, and we never do find out what’s in it.

3. Pacing is critical. Plot out the timeline of emotional highs and lows in a story. It should look like a rolling pattern of highs and lows that crescendo upward to the ultimate crisis. Take advantage of the fact that following any of those emotional peaks, you probably have the reader’s undivided attention. That would be a good time to provide backstory or fill in needed information for the reader – information that may be critical but perhaps not as exciting as what just transpired.

4. Torture your protagonists. Just when the reader thinks that the hero is finally home free, throw in another obstacle. Readers will empathize with the character and be drawn in by the unexpected hurdle.

5. Be original and surprise your readers. Create twists and turns that are totally unexpected, yet believable. This is easier said than done but will go a long way toward making your novel original, gripping, and unpredictable.

6. As a general rule, consider short sentences and short chapters. This is strictly a personal preference, but who can argue with James Patterson’s short chapters or with Robert Parker’s short and engaging sentences? Sentence length can be varied for effect, too, with shorter sentences serving to heighten action or increase tension.

7. Avoid the passive voice. Your readers want action. This is an important rule in almost any type of writing.

8. Keep descriptions brief. Long, drawn-out descriptions of the way characters look, or even setting descriptions, are easily overdone in a thriller. The thriller genre is very different from literary fiction in this regard. Stephen King advises writers to “just say what they see, then get on with the story.”

9. Sustain the reader’s interest throughout. Assess each chapter ending and determine whether the reader has been given enough reason to want to continue reading. Pose a question, end with a minor cliffhanger, or at least ensure that there is enough accumulated tension in the story.

10. Edit aggressively and cut out the fluff. Ernest Hemingway once confided to F. Scott Fitzgerald, “I write one page of masterpiece to 91 pages of shit. I try to put the shit in the wastebasket.”

Dr. DeLuke is professor emeritus of oral and facial surgery at Virginia Commonwealth University and author of the novel Shedrow.

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

For many physicians and other professionals, aspirations of crafting a work of fiction are not uncommon — and with good reason. We are, after all, a generally well-disciplined bunch capable of completing complex tasks, and there is certainly no shortage of excitement and drama in medicine and surgery — ample fodder for thrilling stories. Nonetheless, writing a novel is a major commitment, and it requires persistence, patience, and dedicated time, especially for one with a busy medical career.

Getting started is not easy. Writing workshops are helpful, and in my case, I tried to mentor with some of the best. Before writing my novel, I attended workshops for aspiring novelists, given by noted physician authors Tess Gerritsen (Body Double, The Surgeon) and the late Michael Palmer (The Society, The Fifth Vial).

Writers are often advised to “write about what you know.” In my case, I combined my knowledge of medicine and my experience with the thoroughbred racing world to craft a thriller that one reviewer described as “Dick Francis meets Robin Cook.” For those who have never read the Dick Francis series, he was a renowned crime writer whose novels centered on horse racing in England. Having been an avid reader of both authors, that comparison was the ultimate compliment.

So against that backdrop, here is my distillation of 10 key points on the craft of writing a great thriller, based on my own experience in writing the novel Shedrow, along with some shared wisdom from a few legendary writers.

1. Start with the big “what if.” Any great story starts with that simple “what if” question. What if a series of high-profile executives in the managed care industry are serially murdered (Michael Palmer’s The Society)? What if a multimillion-dollar stallion dies suddenly under very mysterious circumstances on a supposedly secure farm in Kentucky (Dean DeLuke’s Shedrow)?

2. Put a MacGuffin to work in your story. Popularized by Alfred Hitchcock, the MacGuffin is that essential plot element that drives virtually all characters in the story, although it may be rather vague and meaningless to the story itself. In the iconic movie Pulp Fiction, the MacGuffin is the briefcase — everyone wants it, and we never do find out what’s in it.

3. Pacing is critical. Plot out the timeline of emotional highs and lows in a story. It should look like a rolling pattern of highs and lows that crescendo upward to the ultimate crisis. Take advantage of the fact that following any of those emotional peaks, you probably have the reader’s undivided attention. That would be a good time to provide backstory or fill in needed information for the reader – information that may be critical but perhaps not as exciting as what just transpired.

4. Torture your protagonists. Just when the reader thinks that the hero is finally home free, throw in another obstacle. Readers will empathize with the character and be drawn in by the unexpected hurdle.

5. Be original and surprise your readers. Create twists and turns that are totally unexpected, yet believable. This is easier said than done but will go a long way toward making your novel original, gripping, and unpredictable.

6. As a general rule, consider short sentences and short chapters. This is strictly a personal preference, but who can argue with James Patterson’s short chapters or with Robert Parker’s short and engaging sentences? Sentence length can be varied for effect, too, with shorter sentences serving to heighten action or increase tension.

7. Avoid the passive voice. Your readers want action. This is an important rule in almost any type of writing.

8. Keep descriptions brief. Long, drawn-out descriptions of the way characters look, or even setting descriptions, are easily overdone in a thriller. The thriller genre is very different from literary fiction in this regard. Stephen King advises writers to “just say what they see, then get on with the story.”

9. Sustain the reader’s interest throughout. Assess each chapter ending and determine whether the reader has been given enough reason to want to continue reading. Pose a question, end with a minor cliffhanger, or at least ensure that there is enough accumulated tension in the story.

10. Edit aggressively and cut out the fluff. Ernest Hemingway once confided to F. Scott Fitzgerald, “I write one page of masterpiece to 91 pages of shit. I try to put the shit in the wastebasket.”

Dr. DeLuke is professor emeritus of oral and facial surgery at Virginia Commonwealth University and author of the novel Shedrow.

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

For many physicians and other professionals, aspirations of crafting a work of fiction are not uncommon — and with good reason. We are, after all, a generally well-disciplined bunch capable of completing complex tasks, and there is certainly no shortage of excitement and drama in medicine and surgery — ample fodder for thrilling stories. Nonetheless, writing a novel is a major commitment, and it requires persistence, patience, and dedicated time, especially for one with a busy medical career.

Getting started is not easy. Writing workshops are helpful, and in my case, I tried to mentor with some of the best. Before writing my novel, I attended workshops for aspiring novelists, given by noted physician authors Tess Gerritsen (Body Double, The Surgeon) and the late Michael Palmer (The Society, The Fifth Vial).

Writers are often advised to “write about what you know.” In my case, I combined my knowledge of medicine and my experience with the thoroughbred racing world to craft a thriller that one reviewer described as “Dick Francis meets Robin Cook.” For those who have never read the Dick Francis series, he was a renowned crime writer whose novels centered on horse racing in England. Having been an avid reader of both authors, that comparison was the ultimate compliment.

So against that backdrop, here is my distillation of 10 key points on the craft of writing a great thriller, based on my own experience in writing the novel Shedrow, along with some shared wisdom from a few legendary writers.

1. Start with the big “what if.” Any great story starts with that simple “what if” question. What if a series of high-profile executives in the managed care industry are serially murdered (Michael Palmer’s The Society)? What if a multimillion-dollar stallion dies suddenly under very mysterious circumstances on a supposedly secure farm in Kentucky (Dean DeLuke’s Shedrow)?

2. Put a MacGuffin to work in your story. Popularized by Alfred Hitchcock, the MacGuffin is that essential plot element that drives virtually all characters in the story, although it may be rather vague and meaningless to the story itself. In the iconic movie Pulp Fiction, the MacGuffin is the briefcase — everyone wants it, and we never do find out what’s in it.

3. Pacing is critical. Plot out the timeline of emotional highs and lows in a story. It should look like a rolling pattern of highs and lows that crescendo upward to the ultimate crisis. Take advantage of the fact that following any of those emotional peaks, you probably have the reader’s undivided attention. That would be a good time to provide backstory or fill in needed information for the reader – information that may be critical but perhaps not as exciting as what just transpired.

4. Torture your protagonists. Just when the reader thinks that the hero is finally home free, throw in another obstacle. Readers will empathize with the character and be drawn in by the unexpected hurdle.

5. Be original and surprise your readers. Create twists and turns that are totally unexpected, yet believable. This is easier said than done but will go a long way toward making your novel original, gripping, and unpredictable.

6. As a general rule, consider short sentences and short chapters. This is strictly a personal preference, but who can argue with James Patterson’s short chapters or with Robert Parker’s short and engaging sentences? Sentence length can be varied for effect, too, with shorter sentences serving to heighten action or increase tension.

7. Avoid the passive voice. Your readers want action. This is an important rule in almost any type of writing.

8. Keep descriptions brief. Long, drawn-out descriptions of the way characters look, or even setting descriptions, are easily overdone in a thriller. The thriller genre is very different from literary fiction in this regard. Stephen King advises writers to “just say what they see, then get on with the story.”

9. Sustain the reader’s interest throughout. Assess each chapter ending and determine whether the reader has been given enough reason to want to continue reading. Pose a question, end with a minor cliffhanger, or at least ensure that there is enough accumulated tension in the story.

10. Edit aggressively and cut out the fluff. Ernest Hemingway once confided to F. Scott Fitzgerald, “I write one page of masterpiece to 91 pages of shit. I try to put the shit in the wastebasket.”

Dr. DeLuke is professor emeritus of oral and facial surgery at Virginia Commonwealth University and author of the novel Shedrow.

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

The workload of individual hospitalists has long been a hot-button issue. In a 2013 survey of hospitalists, 40% felt workloads were unsafe on a monthly basis, and 22% reported ordering unnecessary testing or procedures because of time pressure.¹ In a 2014 analysis of over 20,000 admissions to an academic hospital medicine service, increasing workload led to increased length of stay and cost per case.² Although these studies suggest a “sweet spot” for hospitalist workload, many groups face constant pressure to increase revenue.

Over the past decade there has been a significant change in how hospital medicine programs are financed. In the 2010 State of Hospital Medicine (SoHM), the median financial support per physician hospitalist in adult hospital medicine groups (HMGs) was $98,253. By the 2020 SoHM, the financial support was $198,750, an increase of $100,497 in just 10 years. When this is combined with the explosive growth in the number of hospitalists, there is one inescapable conclusion – hospital medicine is expensive.

Over this same 10 years, net collections per hospitalist grew from $194,440 in 2010 to $216,779 in 2020, an increase of $22,339. The increase was caused by higher collections per encounter, not more encounters. Additionally, median compensation for adult/internal medicine hospitalists increased over the same period from $215,000 to $307,336, an increase of $92,336, or 43%. That is an increase of 3.7% per year, more than twice the rate of inflation or wage growth in the general economy over the same period. About 75% of this increase was funded by hospital support. It is clear – health care systems continue to find value in investing in hospitalists and hospital medicine programs.

With mounting costs for hospitals, there is pressure for the hospitalist model of care to change or for yearly billable encounters per hospitalist full-time equivalent to increase. Yet, the productivity of hospitalists, as measured by median billable encounters per year has remained flat. The 2010 SoHM listed median number of billable encounters per year for an internal medicine hospitalist as 2,230. In 2020, the number is 2,246 – a trivial 0.7% increase per decade, what amounts to a rounding error. There has been wiggle up and down over the years, but I suspect these are not trends but noise.

So the question is why. I think it is partly because hospital medicine leaders together with the leaders of their health care systems seem to be reaching an equilibrium. Productivity will always remain an expectation. This expectation will vary based on local circumstances. But for many HMGs, the days when productivity is pushed as the primary objective seem to be disappearing. Most hospital leaders seem to now understand that high productivity can be detrimental to other program goals.

But if productivity is flat, do 40% of hospitalists still feel they are providing unsafe care on a monthly basis? Without another study we don’t know, but here are some reasons why I’m hopeful. First, the hospitalist workforce is more experienced than 10 years ago and may be more efficient. Second, hospital medicine groups are larger and are therefore enabled to schedule more flexibly or enact jeopardy systems to level out workload on busy days. And lastly, hospitalists who feel they are providing unsafe care find greener pastures. The 2010 SoHM reported adult hospital medicine programs had a median 14.3% turnover rate. The 2020 SoHM turnover was 10.9%. While this is up from 2018 (7.4%) and 2016 (6.9%), the general trend is down.

Additionally, we all need to consider the possibility that there will be a disruptive innovation that will allow greater productivity for individual hospitalists while maintaining value. It is apparent the EHR is not yet that breakthrough. We all need to keep our eyes open, stay flexible, and be prepared to meet evolving demands on our programs.

We will see constant demands on hospitalists. But I’m hopeful that going forward expectations will increasingly shift away from simply working harder and seeing more patients, toward goals related to improving performance. Training programs generally produce excellent clinicians, but they often do not equip physicians to be excellent hospitalists. Successful hospital medicine programs will recruit lifelong learners and career hospitalists who are flexible and willing to innovate and adapt. The best programs will have structures in place to help excellent clinicians mature into the role of excellent hospitalists, and leaders that create and foster an environment of excellence.

Discover more 2020 SoHM Report data at www.hospitalmedicine.org/sohm.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

References

1. Michtalik HJ et al. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med. 2013;173(5):375-7. doi: 10.1001/jamainternmed.2013.1864.

2. Elliott DJ et al. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786-93. doi: 10.1001/jamainternmed.2014.300.

The workload of individual hospitalists has long been a hot-button issue. In a 2013 survey of hospitalists, 40% felt workloads were unsafe on a monthly basis, and 22% reported ordering unnecessary testing or procedures because of time pressure.¹ In a 2014 analysis of over 20,000 admissions to an academic hospital medicine service, increasing workload led to increased length of stay and cost per case.² Although these studies suggest a “sweet spot” for hospitalist workload, many groups face constant pressure to increase revenue.

Over the past decade there has been a significant change in how hospital medicine programs are financed. In the 2010 State of Hospital Medicine (SoHM), the median financial support per physician hospitalist in adult hospital medicine groups (HMGs) was $98,253. By the 2020 SoHM, the financial support was $198,750, an increase of $100,497 in just 10 years. When this is combined with the explosive growth in the number of hospitalists, there is one inescapable conclusion – hospital medicine is expensive.

Over this same 10 years, net collections per hospitalist grew from $194,440 in 2010 to $216,779 in 2020, an increase of $22,339. The increase was caused by higher collections per encounter, not more encounters. Additionally, median compensation for adult/internal medicine hospitalists increased over the same period from $215,000 to $307,336, an increase of $92,336, or 43%. That is an increase of 3.7% per year, more than twice the rate of inflation or wage growth in the general economy over the same period. About 75% of this increase was funded by hospital support. It is clear – health care systems continue to find value in investing in hospitalists and hospital medicine programs.

With mounting costs for hospitals, there is pressure for the hospitalist model of care to change or for yearly billable encounters per hospitalist full-time equivalent to increase. Yet, the productivity of hospitalists, as measured by median billable encounters per year has remained flat. The 2010 SoHM listed median number of billable encounters per year for an internal medicine hospitalist as 2,230. In 2020, the number is 2,246 – a trivial 0.7% increase per decade, what amounts to a rounding error. There has been wiggle up and down over the years, but I suspect these are not trends but noise.

So the question is why. I think it is partly because hospital medicine leaders together with the leaders of their health care systems seem to be reaching an equilibrium. Productivity will always remain an expectation. This expectation will vary based on local circumstances. But for many HMGs, the days when productivity is pushed as the primary objective seem to be disappearing. Most hospital leaders seem to now understand that high productivity can be detrimental to other program goals.

But if productivity is flat, do 40% of hospitalists still feel they are providing unsafe care on a monthly basis? Without another study we don’t know, but here are some reasons why I’m hopeful. First, the hospitalist workforce is more experienced than 10 years ago and may be more efficient. Second, hospital medicine groups are larger and are therefore enabled to schedule more flexibly or enact jeopardy systems to level out workload on busy days. And lastly, hospitalists who feel they are providing unsafe care find greener pastures. The 2010 SoHM reported adult hospital medicine programs had a median 14.3% turnover rate. The 2020 SoHM turnover was 10.9%. While this is up from 2018 (7.4%) and 2016 (6.9%), the general trend is down.

Additionally, we all need to consider the possibility that there will be a disruptive innovation that will allow greater productivity for individual hospitalists while maintaining value. It is apparent the EHR is not yet that breakthrough. We all need to keep our eyes open, stay flexible, and be prepared to meet evolving demands on our programs.

We will see constant demands on hospitalists. But I’m hopeful that going forward expectations will increasingly shift away from simply working harder and seeing more patients, toward goals related to improving performance. Training programs generally produce excellent clinicians, but they often do not equip physicians to be excellent hospitalists. Successful hospital medicine programs will recruit lifelong learners and career hospitalists who are flexible and willing to innovate and adapt. The best programs will have structures in place to help excellent clinicians mature into the role of excellent hospitalists, and leaders that create and foster an environment of excellence.

Discover more 2020 SoHM Report data at www.hospitalmedicine.org/sohm.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

References

1. Michtalik HJ et al. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med. 2013;173(5):375-7. doi: 10.1001/jamainternmed.2013.1864.

2. Elliott DJ et al. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786-93. doi: 10.1001/jamainternmed.2014.300.

The workload of individual hospitalists has long been a hot-button issue. In a 2013 survey of hospitalists, 40% felt workloads were unsafe on a monthly basis, and 22% reported ordering unnecessary testing or procedures because of time pressure.¹ In a 2014 analysis of over 20,000 admissions to an academic hospital medicine service, increasing workload led to increased length of stay and cost per case.² Although these studies suggest a “sweet spot” for hospitalist workload, many groups face constant pressure to increase revenue.

Over the past decade there has been a significant change in how hospital medicine programs are financed. In the 2010 State of Hospital Medicine (SoHM), the median financial support per physician hospitalist in adult hospital medicine groups (HMGs) was $98,253. By the 2020 SoHM, the financial support was $198,750, an increase of $100,497 in just 10 years. When this is combined with the explosive growth in the number of hospitalists, there is one inescapable conclusion – hospital medicine is expensive.

Over this same 10 years, net collections per hospitalist grew from $194,440 in 2010 to $216,779 in 2020, an increase of $22,339. The increase was caused by higher collections per encounter, not more encounters. Additionally, median compensation for adult/internal medicine hospitalists increased over the same period from $215,000 to $307,336, an increase of $92,336, or 43%. That is an increase of 3.7% per year, more than twice the rate of inflation or wage growth in the general economy over the same period. About 75% of this increase was funded by hospital support. It is clear – health care systems continue to find value in investing in hospitalists and hospital medicine programs.

With mounting costs for hospitals, there is pressure for the hospitalist model of care to change or for yearly billable encounters per hospitalist full-time equivalent to increase. Yet, the productivity of hospitalists, as measured by median billable encounters per year has remained flat. The 2010 SoHM listed median number of billable encounters per year for an internal medicine hospitalist as 2,230. In 2020, the number is 2,246 – a trivial 0.7% increase per decade, what amounts to a rounding error. There has been wiggle up and down over the years, but I suspect these are not trends but noise.

So the question is why. I think it is partly because hospital medicine leaders together with the leaders of their health care systems seem to be reaching an equilibrium. Productivity will always remain an expectation. This expectation will vary based on local circumstances. But for many HMGs, the days when productivity is pushed as the primary objective seem to be disappearing. Most hospital leaders seem to now understand that high productivity can be detrimental to other program goals.

But if productivity is flat, do 40% of hospitalists still feel they are providing unsafe care on a monthly basis? Without another study we don’t know, but here are some reasons why I’m hopeful. First, the hospitalist workforce is more experienced than 10 years ago and may be more efficient. Second, hospital medicine groups are larger and are therefore enabled to schedule more flexibly or enact jeopardy systems to level out workload on busy days. And lastly, hospitalists who feel they are providing unsafe care find greener pastures. The 2010 SoHM reported adult hospital medicine programs had a median 14.3% turnover rate. The 2020 SoHM turnover was 10.9%. While this is up from 2018 (7.4%) and 2016 (6.9%), the general trend is down.

Additionally, we all need to consider the possibility that there will be a disruptive innovation that will allow greater productivity for individual hospitalists while maintaining value. It is apparent the EHR is not yet that breakthrough. We all need to keep our eyes open, stay flexible, and be prepared to meet evolving demands on our programs.

We will see constant demands on hospitalists. But I’m hopeful that going forward expectations will increasingly shift away from simply working harder and seeing more patients, toward goals related to improving performance. Training programs generally produce excellent clinicians, but they often do not equip physicians to be excellent hospitalists. Successful hospital medicine programs will recruit lifelong learners and career hospitalists who are flexible and willing to innovate and adapt. The best programs will have structures in place to help excellent clinicians mature into the role of excellent hospitalists, and leaders that create and foster an environment of excellence.

Discover more 2020 SoHM Report data at www.hospitalmedicine.org/sohm.

Dr. Frederickson is medical director, hospital medicine and palliative care, at CHI Health, Omaha, Neb., and assistant professor at Creighton University, Omaha.

References

1. Michtalik HJ et al. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med. 2013;173(5):375-7. doi: 10.1001/jamainternmed.2013.1864.

2. Elliott DJ et al. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786-93. doi: 10.1001/jamainternmed.2014.300.

The practice of pediatric hospital medicine (PHM) has been evolving and rapidly expanding over the last several decades. Not only has the scope of clinical practice matured and become more defined, but hospitalists now also have the responsibility to advance the performance of hospitals and health care systems. Pediatric hospitalists are increasingly incorporating medical education, research, high-value care, patient quality and safety initiatives, and process improvement into their careers.¹ As a result, pediatric hospitalists are occupying a wider range of administrative and leadership positions within the health care system.

The field of PHM has highlighted the importance of leadership in the practice of hospital medicine by dedicating a chapter to “Leadership in Healthcare” in the PHM Core Competencies.¹ The competencies define the expertise required of hospitalists and serve as guidance for the development of education, training, and career development series. Hospitalists may seek out opportunities for leadership training at an institutional or national level. Options may include advanced degrees, national conferences, division training seminars, or self-directed learning through reading or observational experiences. Unfortunately, all of these take time and motivation. As a result, hospitalists tend to pursue these opportunities only after they have already been appointed to leadership positions.

PHM fellowship is the optimal time to build a foundation of leadership skills. Over the course of a 2-year fellowship, fellows have a combined 16 weeks dedicated to educational activities beyond direct patient care.² The Accreditation Council for Graduate Medical Education (ACGME) encourages educational innovation during this time, allowing programs to create unique opportunities for their fellows that will promote progress towards their ultimate career goals.³ This curricular framework provides the flexibility to integrate leadership training into fellowship training.

Many fellows are eager for leadership experiences and mentorship, myself included. As a pediatric chief resident, I was immersed in a diverse range of clinical, educational, research, and administrative responsibilities. I found myself in a leadership position with no prior education on how to manage people or team dynamics, make high-stress decisions on behalf of a group of people, or handle conflict. Although I learned new strategies on a daily basis, the experience showed me how much more I still had to learn in order to be a successful leader. This was one of the reasons I decided to pursue fellowship training. I think many PHM fellowship applicants feel similarly. They may have served in a leadership position in the past but feel underprepared to fulfill leadership positions in the next phase of their careers.

But despite this eagerness, evidence suggests that fellows do not feel that they receive as much management training as they need to start their careers. In a 2014 survey of PHM fellowship graduates, many held formal leadership positions within their institution (23/51) and within national organizations (6/51), despite having only five years of hospitalist experience on average (including time spent in fellowship). When asked about training needs, respondents identified “hospital program management” as an area where they wished they received more training during fellowship.⁴

Anyone who has gone through the PHM fellowship interview process can tell you that a common refrain of program directors is, “One of the goals of our program is to create future leaders in PHM.” This led me to wonder: how do fellowship programs prepare their fellows for future leadership positions?

I began my fellowship training at Nationwide Children’s Hospital in the summer of 2020. The program had just designed a longitudinal leadership elective, which the second-year fellow and I decided to pilot together. As I reflected on the first half of this academic year, I realized that it is unique experiences like this elective that make me thankful I pursued fellowship. I want to share with the hospitalist community the structure of the elective and why it has been particularly valuable with the hope that it will inspire similar opportunities for other fellows.

The program is semi-structured but allows the fellow and preceptors the flexibility to decide what activities would benefit that particular fellow. We attend a variety of administrative and committee meetings with each preceptor that expose us to the responsibilities of their positions, their leadership style in action, their approach to crisis management, and differences in divisional operations. On a monthly basis we meet with a preceptor to discuss a topic related to leadership. Examples of topics include how to run a more effective meeting, barriers to organizational change, leading in crisis, and the importance of mission, vision, values, and goals of organizations. The preceptor sends us articles or other learning materials they have found useful on the topic, and these serve as a starting point for our discussions. These discussions provide a point of reflection as we apply the day’s concept to our own prior experiences or to our observations during the elective.

The combination of learning experiences, discussions, and dedicated preceptorship has prepared me far better for future leadership than my past personal and observational experiences. I have summarized my top three reasons why this structure of leadership development is particularly valuable to me as a fellow.

First, the longitudinal structure of the elective allows us to learn from multiple preceptors over the course of the academic year. The preceptors include the current chief of hospital pediatrics at Nationwide Children’s Hospital; the division director of hospital medicine at the Ohio State University Wexner Medical Center; and the physician lead for hospital medicine at one of the satellite hospitals in the region. With faculty from the Department of Pediatrics and the Department of Internal Medicine-Pediatrics in these leadership positions, we have the unique ability to compare and contrast operational systems between the two different hospital systems.

Recently, we also had the opportunity to meet with both the chairman of the department of pediatrics and chief medical officer. All of these physician leaders hold a variety of administrative roles and have differing leadership philosophies, each providing useful insights. For instance, one leader ensures his team holds him accountable as the leader by always asking for honest feedback. He recommends telling those you work with to “never let me fail.” Another leader acknowledges that creating five-year plans can be daunting but encouraged us to still be intentional with our direction on a smaller scale by writing down goals for the year and sharing with a mentor. Ultimately, I came away with a wide variety of perspectives to reference as I go forward.

Second, the learning is contextualized. I can take concepts that I learn through reading and discussions and construct meaning based on observations from meetings or other encounters with different leaders. For example, after reviewing several articles on strategies to make meetings more effective, I started noticing what went well and what didn’t go well in every meeting I attended. I observed preceptors employing many of the strategies successfully with positive feedback. This included not only simple practices, such as setting an agenda to provide a compass for the conversation, but also more nuanced practices like controlling the meeting but not the conversation.

After reading about leadership styles I also found myself analyzing the qualities and strategies of leaders I encountered and reflecting on their approach, noticing what I could possibly interlace in my own practice. Several of the leaders I spoke with during the elective recommended paying attention to the actions of the ineffective bosses or mentors because they can teach you something too: how not to act. I even started applying this strategy to the popular television series The Office – Michael Scott, the regional manager of a fictional paper company, demonstrates some of the best and worst leadership skills in every episode. I am developing a repertoire of strategies to lead and motivate people.

Finally, the design allows for real-time application of new methods to my current practice. One particularly useful tool I have learned is Leader Standard Work, a systematic method to get leaders to maintain stability, problem solve, and drive continuous improvement within their organization.⁵ I have used elements of Leader Standard Work on a personal level to improve my time management skills and increase my productivity. For example, I reconceptualized my calendar as a standardized checklist and I organized it to allot more time to critical activities, such as my research and scholarly output, and less on administrative tasks. I am also implementing changes to how I prepare and run meetings, collaborate, and communicate with members of my research team.

Mastery requires practice and feedback, so applying concepts even on a small, personal scale shortly after learning them has been very valuable. Over the last several months I have often wished I had this type of structured leadership education during my year as a chief resident. I think I could have been more intentional in my decision-making, possibly being a stronger leader for the program. Now that I am transferring skills into practice right away, I am setting the stage for lasting changes in behavior that will hopefully benefit all those that I work with in the future.

Leadership development through a customizable longitudinal elective may be an effective way to prepare PHM fellow graduates for future leadership positions. Fellows can emerge with the skills and real-world practice to allow them to feel confident in future positions. However, leadership doesn’t end when we get the position. We must remember to continuously ask for feedback and build upon our experiences to evolve as leaders in PHM.
 

Dr. Westphal is a first-year pediatric hospital medicine fellow at Nationwide Children’s Hospital in Columbus, Ohio with an interest in improving the delivery of quality care for hospitalized infants.

References

1. Maniscalco, J, et al. The Pediatric Hospital Medicine Core Competencies: 2020 Revision. Introduction and Methodology (C). J Hosp Med. 2020;S1;E12-E17. doi: 10.12788/jhm.3391.

2. Jerardi KE, et al; Council of Pediatric Hospital Medicine Fellowship Directors. Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships. Pediatrics. 2017 Jul;140(1):e20170698. doi: 10.1542/peds.2017-0698.

3. ACGME Program Requirements for Graduate Medical Education in Pediatric Hospital Medicine. 2020 Edition. Accessed 2021 Jan 14.

4. Oshimura, JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7. doi: 10.1542/hpeds.2016-0031.

5. Murli, J. Standard Work for Lean Leaders: One of the Keys to Sustaining Performance Gains. Lean Institute Enterprise, Lean Institute Enterprise Inc. 4 Dec 2013. www.lean.org/common/display/?o=2493

The practice of pediatric hospital medicine (PHM) has been evolving and rapidly expanding over the last several decades. Not only has the scope of clinical practice matured and become more defined, but hospitalists now also have the responsibility to advance the performance of hospitals and health care systems. Pediatric hospitalists are increasingly incorporating medical education, research, high-value care, patient quality and safety initiatives, and process improvement into their careers.¹ As a result, pediatric hospitalists are occupying a wider range of administrative and leadership positions within the health care system.

The field of PHM has highlighted the importance of leadership in the practice of hospital medicine by dedicating a chapter to “Leadership in Healthcare” in the PHM Core Competencies.¹ The competencies define the expertise required of hospitalists and serve as guidance for the development of education, training, and career development series. Hospitalists may seek out opportunities for leadership training at an institutional or national level. Options may include advanced degrees, national conferences, division training seminars, or self-directed learning through reading or observational experiences. Unfortunately, all of these take time and motivation. As a result, hospitalists tend to pursue these opportunities only after they have already been appointed to leadership positions.

PHM fellowship is the optimal time to build a foundation of leadership skills. Over the course of a 2-year fellowship, fellows have a combined 16 weeks dedicated to educational activities beyond direct patient care.² The Accreditation Council for Graduate Medical Education (ACGME) encourages educational innovation during this time, allowing programs to create unique opportunities for their fellows that will promote progress towards their ultimate career goals.³ This curricular framework provides the flexibility to integrate leadership training into fellowship training.

Many fellows are eager for leadership experiences and mentorship, myself included. As a pediatric chief resident, I was immersed in a diverse range of clinical, educational, research, and administrative responsibilities. I found myself in a leadership position with no prior education on how to manage people or team dynamics, make high-stress decisions on behalf of a group of people, or handle conflict. Although I learned new strategies on a daily basis, the experience showed me how much more I still had to learn in order to be a successful leader. This was one of the reasons I decided to pursue fellowship training. I think many PHM fellowship applicants feel similarly. They may have served in a leadership position in the past but feel underprepared to fulfill leadership positions in the next phase of their careers.

But despite this eagerness, evidence suggests that fellows do not feel that they receive as much management training as they need to start their careers. In a 2014 survey of PHM fellowship graduates, many held formal leadership positions within their institution (23/51) and within national organizations (6/51), despite having only five years of hospitalist experience on average (including time spent in fellowship). When asked about training needs, respondents identified “hospital program management” as an area where they wished they received more training during fellowship.⁴

Anyone who has gone through the PHM fellowship interview process can tell you that a common refrain of program directors is, “One of the goals of our program is to create future leaders in PHM.” This led me to wonder: how do fellowship programs prepare their fellows for future leadership positions?

I began my fellowship training at Nationwide Children’s Hospital in the summer of 2020. The program had just designed a longitudinal leadership elective, which the second-year fellow and I decided to pilot together. As I reflected on the first half of this academic year, I realized that it is unique experiences like this elective that make me thankful I pursued fellowship. I want to share with the hospitalist community the structure of the elective and why it has been particularly valuable with the hope that it will inspire similar opportunities for other fellows.

The program is semi-structured but allows the fellow and preceptors the flexibility to decide what activities would benefit that particular fellow. We attend a variety of administrative and committee meetings with each preceptor that expose us to the responsibilities of their positions, their leadership style in action, their approach to crisis management, and differences in divisional operations. On a monthly basis we meet with a preceptor to discuss a topic related to leadership. Examples of topics include how to run a more effective meeting, barriers to organizational change, leading in crisis, and the importance of mission, vision, values, and goals of organizations. The preceptor sends us articles or other learning materials they have found useful on the topic, and these serve as a starting point for our discussions. These discussions provide a point of reflection as we apply the day’s concept to our own prior experiences or to our observations during the elective.

The combination of learning experiences, discussions, and dedicated preceptorship has prepared me far better for future leadership than my past personal and observational experiences. I have summarized my top three reasons why this structure of leadership development is particularly valuable to me as a fellow.

First, the longitudinal structure of the elective allows us to learn from multiple preceptors over the course of the academic year. The preceptors include the current chief of hospital pediatrics at Nationwide Children’s Hospital; the division director of hospital medicine at the Ohio State University Wexner Medical Center; and the physician lead for hospital medicine at one of the satellite hospitals in the region. With faculty from the Department of Pediatrics and the Department of Internal Medicine-Pediatrics in these leadership positions, we have the unique ability to compare and contrast operational systems between the two different hospital systems.

Recently, we also had the opportunity to meet with both the chairman of the department of pediatrics and chief medical officer. All of these physician leaders hold a variety of administrative roles and have differing leadership philosophies, each providing useful insights. For instance, one leader ensures his team holds him accountable as the leader by always asking for honest feedback. He recommends telling those you work with to “never let me fail.” Another leader acknowledges that creating five-year plans can be daunting but encouraged us to still be intentional with our direction on a smaller scale by writing down goals for the year and sharing with a mentor. Ultimately, I came away with a wide variety of perspectives to reference as I go forward.

Second, the learning is contextualized. I can take concepts that I learn through reading and discussions and construct meaning based on observations from meetings or other encounters with different leaders. For example, after reviewing several articles on strategies to make meetings more effective, I started noticing what went well and what didn’t go well in every meeting I attended. I observed preceptors employing many of the strategies successfully with positive feedback. This included not only simple practices, such as setting an agenda to provide a compass for the conversation, but also more nuanced practices like controlling the meeting but not the conversation.

After reading about leadership styles I also found myself analyzing the qualities and strategies of leaders I encountered and reflecting on their approach, noticing what I could possibly interlace in my own practice. Several of the leaders I spoke with during the elective recommended paying attention to the actions of the ineffective bosses or mentors because they can teach you something too: how not to act. I even started applying this strategy to the popular television series The Office – Michael Scott, the regional manager of a fictional paper company, demonstrates some of the best and worst leadership skills in every episode. I am developing a repertoire of strategies to lead and motivate people.

Finally, the design allows for real-time application of new methods to my current practice. One particularly useful tool I have learned is Leader Standard Work, a systematic method to get leaders to maintain stability, problem solve, and drive continuous improvement within their organization.⁵ I have used elements of Leader Standard Work on a personal level to improve my time management skills and increase my productivity. For example, I reconceptualized my calendar as a standardized checklist and I organized it to allot more time to critical activities, such as my research and scholarly output, and less on administrative tasks. I am also implementing changes to how I prepare and run meetings, collaborate, and communicate with members of my research team.

Mastery requires practice and feedback, so applying concepts even on a small, personal scale shortly after learning them has been very valuable. Over the last several months I have often wished I had this type of structured leadership education during my year as a chief resident. I think I could have been more intentional in my decision-making, possibly being a stronger leader for the program. Now that I am transferring skills into practice right away, I am setting the stage for lasting changes in behavior that will hopefully benefit all those that I work with in the future.

Leadership development through a customizable longitudinal elective may be an effective way to prepare PHM fellow graduates for future leadership positions. Fellows can emerge with the skills and real-world practice to allow them to feel confident in future positions. However, leadership doesn’t end when we get the position. We must remember to continuously ask for feedback and build upon our experiences to evolve as leaders in PHM.
 

Dr. Westphal is a first-year pediatric hospital medicine fellow at Nationwide Children’s Hospital in Columbus, Ohio with an interest in improving the delivery of quality care for hospitalized infants.

References

1. Maniscalco, J, et al. The Pediatric Hospital Medicine Core Competencies: 2020 Revision. Introduction and Methodology (C). J Hosp Med. 2020;S1;E12-E17. doi: 10.12788/jhm.3391.

2. Jerardi KE, et al; Council of Pediatric Hospital Medicine Fellowship Directors. Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships. Pediatrics. 2017 Jul;140(1):e20170698. doi: 10.1542/peds.2017-0698.

3. ACGME Program Requirements for Graduate Medical Education in Pediatric Hospital Medicine. 2020 Edition. Accessed 2021 Jan 14.

4. Oshimura, JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7. doi: 10.1542/hpeds.2016-0031.

5. Murli, J. Standard Work for Lean Leaders: One of the Keys to Sustaining Performance Gains. Lean Institute Enterprise, Lean Institute Enterprise Inc. 4 Dec 2013. www.lean.org/common/display/?o=2493

The practice of pediatric hospital medicine (PHM) has been evolving and rapidly expanding over the last several decades. Not only has the scope of clinical practice matured and become more defined, but hospitalists now also have the responsibility to advance the performance of hospitals and health care systems. Pediatric hospitalists are increasingly incorporating medical education, research, high-value care, patient quality and safety initiatives, and process improvement into their careers.¹ As a result, pediatric hospitalists are occupying a wider range of administrative and leadership positions within the health care system.

The field of PHM has highlighted the importance of leadership in the practice of hospital medicine by dedicating a chapter to “Leadership in Healthcare” in the PHM Core Competencies.¹ The competencies define the expertise required of hospitalists and serve as guidance for the development of education, training, and career development series. Hospitalists may seek out opportunities for leadership training at an institutional or national level. Options may include advanced degrees, national conferences, division training seminars, or self-directed learning through reading or observational experiences. Unfortunately, all of these take time and motivation. As a result, hospitalists tend to pursue these opportunities only after they have already been appointed to leadership positions.

PHM fellowship is the optimal time to build a foundation of leadership skills. Over the course of a 2-year fellowship, fellows have a combined 16 weeks dedicated to educational activities beyond direct patient care.² The Accreditation Council for Graduate Medical Education (ACGME) encourages educational innovation during this time, allowing programs to create unique opportunities for their fellows that will promote progress towards their ultimate career goals.³ This curricular framework provides the flexibility to integrate leadership training into fellowship training.

Many fellows are eager for leadership experiences and mentorship, myself included. As a pediatric chief resident, I was immersed in a diverse range of clinical, educational, research, and administrative responsibilities. I found myself in a leadership position with no prior education on how to manage people or team dynamics, make high-stress decisions on behalf of a group of people, or handle conflict. Although I learned new strategies on a daily basis, the experience showed me how much more I still had to learn in order to be a successful leader. This was one of the reasons I decided to pursue fellowship training. I think many PHM fellowship applicants feel similarly. They may have served in a leadership position in the past but feel underprepared to fulfill leadership positions in the next phase of their careers.

But despite this eagerness, evidence suggests that fellows do not feel that they receive as much management training as they need to start their careers. In a 2014 survey of PHM fellowship graduates, many held formal leadership positions within their institution (23/51) and within national organizations (6/51), despite having only five years of hospitalist experience on average (including time spent in fellowship). When asked about training needs, respondents identified “hospital program management” as an area where they wished they received more training during fellowship.⁴

Anyone who has gone through the PHM fellowship interview process can tell you that a common refrain of program directors is, “One of the goals of our program is to create future leaders in PHM.” This led me to wonder: how do fellowship programs prepare their fellows for future leadership positions?

I began my fellowship training at Nationwide Children’s Hospital in the summer of 2020. The program had just designed a longitudinal leadership elective, which the second-year fellow and I decided to pilot together. As I reflected on the first half of this academic year, I realized that it is unique experiences like this elective that make me thankful I pursued fellowship. I want to share with the hospitalist community the structure of the elective and why it has been particularly valuable with the hope that it will inspire similar opportunities for other fellows.

The program is semi-structured but allows the fellow and preceptors the flexibility to decide what activities would benefit that particular fellow. We attend a variety of administrative and committee meetings with each preceptor that expose us to the responsibilities of their positions, their leadership style in action, their approach to crisis management, and differences in divisional operations. On a monthly basis we meet with a preceptor to discuss a topic related to leadership. Examples of topics include how to run a more effective meeting, barriers to organizational change, leading in crisis, and the importance of mission, vision, values, and goals of organizations. The preceptor sends us articles or other learning materials they have found useful on the topic, and these serve as a starting point for our discussions. These discussions provide a point of reflection as we apply the day’s concept to our own prior experiences or to our observations during the elective.

The combination of learning experiences, discussions, and dedicated preceptorship has prepared me far better for future leadership than my past personal and observational experiences. I have summarized my top three reasons why this structure of leadership development is particularly valuable to me as a fellow.

First, the longitudinal structure of the elective allows us to learn from multiple preceptors over the course of the academic year. The preceptors include the current chief of hospital pediatrics at Nationwide Children’s Hospital; the division director of hospital medicine at the Ohio State University Wexner Medical Center; and the physician lead for hospital medicine at one of the satellite hospitals in the region. With faculty from the Department of Pediatrics and the Department of Internal Medicine-Pediatrics in these leadership positions, we have the unique ability to compare and contrast operational systems between the two different hospital systems.

Recently, we also had the opportunity to meet with both the chairman of the department of pediatrics and chief medical officer. All of these physician leaders hold a variety of administrative roles and have differing leadership philosophies, each providing useful insights. For instance, one leader ensures his team holds him accountable as the leader by always asking for honest feedback. He recommends telling those you work with to “never let me fail.” Another leader acknowledges that creating five-year plans can be daunting but encouraged us to still be intentional with our direction on a smaller scale by writing down goals for the year and sharing with a mentor. Ultimately, I came away with a wide variety of perspectives to reference as I go forward.

Second, the learning is contextualized. I can take concepts that I learn through reading and discussions and construct meaning based on observations from meetings or other encounters with different leaders. For example, after reviewing several articles on strategies to make meetings more effective, I started noticing what went well and what didn’t go well in every meeting I attended. I observed preceptors employing many of the strategies successfully with positive feedback. This included not only simple practices, such as setting an agenda to provide a compass for the conversation, but also more nuanced practices like controlling the meeting but not the conversation.

After reading about leadership styles I also found myself analyzing the qualities and strategies of leaders I encountered and reflecting on their approach, noticing what I could possibly interlace in my own practice. Several of the leaders I spoke with during the elective recommended paying attention to the actions of the ineffective bosses or mentors because they can teach you something too: how not to act. I even started applying this strategy to the popular television series The Office – Michael Scott, the regional manager of a fictional paper company, demonstrates some of the best and worst leadership skills in every episode. I am developing a repertoire of strategies to lead and motivate people.

Finally, the design allows for real-time application of new methods to my current practice. One particularly useful tool I have learned is Leader Standard Work, a systematic method to get leaders to maintain stability, problem solve, and drive continuous improvement within their organization.⁵ I have used elements of Leader Standard Work on a personal level to improve my time management skills and increase my productivity. For example, I reconceptualized my calendar as a standardized checklist and I organized it to allot more time to critical activities, such as my research and scholarly output, and less on administrative tasks. I am also implementing changes to how I prepare and run meetings, collaborate, and communicate with members of my research team.

Mastery requires practice and feedback, so applying concepts even on a small, personal scale shortly after learning them has been very valuable. Over the last several months I have often wished I had this type of structured leadership education during my year as a chief resident. I think I could have been more intentional in my decision-making, possibly being a stronger leader for the program. Now that I am transferring skills into practice right away, I am setting the stage for lasting changes in behavior that will hopefully benefit all those that I work with in the future.

Leadership development through a customizable longitudinal elective may be an effective way to prepare PHM fellow graduates for future leadership positions. Fellows can emerge with the skills and real-world practice to allow them to feel confident in future positions. However, leadership doesn’t end when we get the position. We must remember to continuously ask for feedback and build upon our experiences to evolve as leaders in PHM.
 

Dr. Westphal is a first-year pediatric hospital medicine fellow at Nationwide Children’s Hospital in Columbus, Ohio with an interest in improving the delivery of quality care for hospitalized infants.

References

1. Maniscalco, J, et al. The Pediatric Hospital Medicine Core Competencies: 2020 Revision. Introduction and Methodology (C). J Hosp Med. 2020;S1;E12-E17. doi: 10.12788/jhm.3391.

2. Jerardi KE, et al; Council of Pediatric Hospital Medicine Fellowship Directors. Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships. Pediatrics. 2017 Jul;140(1):e20170698. doi: 10.1542/peds.2017-0698.

3. ACGME Program Requirements for Graduate Medical Education in Pediatric Hospital Medicine. 2020 Edition. Accessed 2021 Jan 14.

4. Oshimura, JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7. doi: 10.1542/hpeds.2016-0031.

5. Murli, J. Standard Work for Lean Leaders: One of the Keys to Sustaining Performance Gains. Lean Institute Enterprise, Lean Institute Enterprise Inc. 4 Dec 2013. www.lean.org/common/display/?o=2493

The Americans with Disabilities Act (ADA) carries mandates most physician practices must follow to make their offices accessible so as to not discriminate against patients with disabilities when providing care. And 7 years ago, the government raised the penalties for failing to do so. So it might be time to re-educate yourself on what the ADA requires.

ADA compliance is not an issue that we talk about or provide training for in medical schools or with our professional organizations. Since fines for small businesses are now $75,000 for a first offense and $150,000 for each subsequent violation, this could be an expensive oversight that malpractice and other liability policies will not cover.

A 2019 study in Boston examined physicians’ knowledge of legal obligations when caring for patients with disabilities. Researchers concluded that most physicians interviewed “exhibited a superficial or incorrect understanding of their legal responsibilities to patients with a disability.” If you feel you’re in that boat, you might want to consult federal guidance with information and common questions physicians ask about their ADA obligations.

The ADA defines a person with a disability as someone with “a physical or mental impairment that substantially limits one or more life activities”; someone with a record of such an impairment; or someone who is “regarded as having such an impairment.” Among the ADA standards required for accessible exam rooms, according to the guidance:

• The entry door to the exam room should be a minimum width of 32 inches when the door is opened at a 90-degree angle.
• There should be a minimum of 30 by 48 inches of clear floor space next to the exam table.
• An accessible exam table should be able to be lowered to the height of the patient’s wheelchair seat, 17 to 19 inches from the floor.

This does not mean that all of your exam rooms must meet these standards, of course; but if you see any patients with disabilities – and who doesn’t? – you need at least one room that meets the criteria.

Federal guidance also includes requirements on removal of architectural barriers, accessible parking, and entrance and maneuvering spaces – which apply to both for-profit and nonprofit organizations. Among them:

• Designated accessible parking spaces must be included among any parking the business provides for the public “if doing so is readily achievable.” Those parking spaces should be the closest to the accessible entrance, on level ground. The spaces should be at least eight feet wide, with an access aisle on either side.
• For accessible spaces for cars, the adjacent access aisle must be at least five feet wide; for van spaces, eight feet wide.
• “If achievable,” an accessible service counter must have a maximum height of 36 inches, with a clear floor space of 30 by 48 inches to permit the use of a wheelchair.

A common misconception is that only new construction and alterations need to be accessible, and that older facilities are “grandfathered,” but that’s not true. Because the ADA is a civil rights law and not a building code, ADA rules apply equally to all facilities, young and old. This is particularly important to remember in light of the long-standing cottage industry of attorneys who sue small businesses for alleged ADA violations.

Another common mistake made by physicians who lease their office space is to assume that their landlord is responsible for meeting all ADA obligations. In fact, The ADA places the legal obligation on both the landlord and the tenant. The landlord and the tenant may decide among themselves who will actually make the changes and provide the aids and services, but both remain legally responsible.

Another aspect that you might not have thought of is access to your website. While ADA applicability to online services remains vague, lawsuits have been filed, and are likely to increase. Online accessibility issues that have been identified include:
 

• Ability to find and process information on a website (e.g., providing audio descriptions for video content, for the sight-impaired).
• Ability to navigate and use a website (e.g., ensuring that all site functions are easily accessible with only a keyboard).
• Ability to comprehend all information (including clearly understandable error messages).

Hearing-impaired patients present their own considerations for delivering adequate care, which I will discuss in my next column.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The Americans with Disabilities Act (ADA) carries mandates most physician practices must follow to make their offices accessible so as to not discriminate against patients with disabilities when providing care. And 7 years ago, the government raised the penalties for failing to do so. So it might be time to re-educate yourself on what the ADA requires.

ADA compliance is not an issue that we talk about or provide training for in medical schools or with our professional organizations. Since fines for small businesses are now $75,000 for a first offense and $150,000 for each subsequent violation, this could be an expensive oversight that malpractice and other liability policies will not cover.

A 2019 study in Boston examined physicians’ knowledge of legal obligations when caring for patients with disabilities. Researchers concluded that most physicians interviewed “exhibited a superficial or incorrect understanding of their legal responsibilities to patients with a disability.” If you feel you’re in that boat, you might want to consult federal guidance with information and common questions physicians ask about their ADA obligations.

The ADA defines a person with a disability as someone with “a physical or mental impairment that substantially limits one or more life activities”; someone with a record of such an impairment; or someone who is “regarded as having such an impairment.” Among the ADA standards required for accessible exam rooms, according to the guidance:

• The entry door to the exam room should be a minimum width of 32 inches when the door is opened at a 90-degree angle.
• There should be a minimum of 30 by 48 inches of clear floor space next to the exam table.
• An accessible exam table should be able to be lowered to the height of the patient’s wheelchair seat, 17 to 19 inches from the floor.

This does not mean that all of your exam rooms must meet these standards, of course; but if you see any patients with disabilities – and who doesn’t? – you need at least one room that meets the criteria.

Federal guidance also includes requirements on removal of architectural barriers, accessible parking, and entrance and maneuvering spaces – which apply to both for-profit and nonprofit organizations. Among them:

• Designated accessible parking spaces must be included among any parking the business provides for the public “if doing so is readily achievable.” Those parking spaces should be the closest to the accessible entrance, on level ground. The spaces should be at least eight feet wide, with an access aisle on either side.
• For accessible spaces for cars, the adjacent access aisle must be at least five feet wide; for van spaces, eight feet wide.
• “If achievable,” an accessible service counter must have a maximum height of 36 inches, with a clear floor space of 30 by 48 inches to permit the use of a wheelchair.

A common misconception is that only new construction and alterations need to be accessible, and that older facilities are “grandfathered,” but that’s not true. Because the ADA is a civil rights law and not a building code, ADA rules apply equally to all facilities, young and old. This is particularly important to remember in light of the long-standing cottage industry of attorneys who sue small businesses for alleged ADA violations.

Another common mistake made by physicians who lease their office space is to assume that their landlord is responsible for meeting all ADA obligations. In fact, The ADA places the legal obligation on both the landlord and the tenant. The landlord and the tenant may decide among themselves who will actually make the changes and provide the aids and services, but both remain legally responsible.

Another aspect that you might not have thought of is access to your website. While ADA applicability to online services remains vague, lawsuits have been filed, and are likely to increase. Online accessibility issues that have been identified include:
 

• Ability to find and process information on a website (e.g., providing audio descriptions for video content, for the sight-impaired).
• Ability to navigate and use a website (e.g., ensuring that all site functions are easily accessible with only a keyboard).
• Ability to comprehend all information (including clearly understandable error messages).

Hearing-impaired patients present their own considerations for delivering adequate care, which I will discuss in my next column.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

The Americans with Disabilities Act (ADA) carries mandates most physician practices must follow to make their offices accessible so as to not discriminate against patients with disabilities when providing care. And 7 years ago, the government raised the penalties for failing to do so. So it might be time to re-educate yourself on what the ADA requires.

ADA compliance is not an issue that we talk about or provide training for in medical schools or with our professional organizations. Since fines for small businesses are now $75,000 for a first offense and $150,000 for each subsequent violation, this could be an expensive oversight that malpractice and other liability policies will not cover.

A 2019 study in Boston examined physicians’ knowledge of legal obligations when caring for patients with disabilities. Researchers concluded that most physicians interviewed “exhibited a superficial or incorrect understanding of their legal responsibilities to patients with a disability.” If you feel you’re in that boat, you might want to consult federal guidance with information and common questions physicians ask about their ADA obligations.

The ADA defines a person with a disability as someone with “a physical or mental impairment that substantially limits one or more life activities”; someone with a record of such an impairment; or someone who is “regarded as having such an impairment.” Among the ADA standards required for accessible exam rooms, according to the guidance:

• The entry door to the exam room should be a minimum width of 32 inches when the door is opened at a 90-degree angle.
• There should be a minimum of 30 by 48 inches of clear floor space next to the exam table.
• An accessible exam table should be able to be lowered to the height of the patient’s wheelchair seat, 17 to 19 inches from the floor.

This does not mean that all of your exam rooms must meet these standards, of course; but if you see any patients with disabilities – and who doesn’t? – you need at least one room that meets the criteria.

Federal guidance also includes requirements on removal of architectural barriers, accessible parking, and entrance and maneuvering spaces – which apply to both for-profit and nonprofit organizations. Among them:

• Designated accessible parking spaces must be included among any parking the business provides for the public “if doing so is readily achievable.” Those parking spaces should be the closest to the accessible entrance, on level ground. The spaces should be at least eight feet wide, with an access aisle on either side.
• For accessible spaces for cars, the adjacent access aisle must be at least five feet wide; for van spaces, eight feet wide.
• “If achievable,” an accessible service counter must have a maximum height of 36 inches, with a clear floor space of 30 by 48 inches to permit the use of a wheelchair.

A common misconception is that only new construction and alterations need to be accessible, and that older facilities are “grandfathered,” but that’s not true. Because the ADA is a civil rights law and not a building code, ADA rules apply equally to all facilities, young and old. This is particularly important to remember in light of the long-standing cottage industry of attorneys who sue small businesses for alleged ADA violations.

Another common mistake made by physicians who lease their office space is to assume that their landlord is responsible for meeting all ADA obligations. In fact, The ADA places the legal obligation on both the landlord and the tenant. The landlord and the tenant may decide among themselves who will actually make the changes and provide the aids and services, but both remain legally responsible.

Another aspect that you might not have thought of is access to your website. While ADA applicability to online services remains vague, lawsuits have been filed, and are likely to increase. Online accessibility issues that have been identified include:
 

• Ability to find and process information on a website (e.g., providing audio descriptions for video content, for the sight-impaired).
• Ability to navigate and use a website (e.g., ensuring that all site functions are easily accessible with only a keyboard).
• Ability to comprehend all information (including clearly understandable error messages).

Hearing-impaired patients present their own considerations for delivering adequate care, which I will discuss in my next column.
 

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

I arrived on the 6th floor nursing unit one day last fall to find halls abuzz with people. Something didn’t feel right, and then I a saw a nursing colleague with tears streaming down her face. My heart dropped. She looked up at me and said, “Dr Hass, K died last night.” She started to sob. I stood dumbfounded for a moment. We had lost a beloved coworker to COVID.

There has been a collective sense of grief in our country since the beginning of the COVID-19 pandemic as we have all been suffering losses: smiles, touch, in-person relationships, a “normal life.” But it went to another level for us at Alta Bates Summit Medical Center in Oakland, Calif., with the passing of a couple of our beloved teammates in the fall. Strong emotions triggered by these events caused me to pause and think: “What is grief? Is it another word for sadness? How do we work through it?”

What is the difference between sadness and grief? While related, they are temporally and functionally quite different. Sadness is an emotion, and like all emotions, we feel it in brief episodes. Those moments of profound sadness only last minutes at a time. Sadness leads to decreased physiological arousal, especially after crying. When less intense, the physiological slowing is thought to allow for some mental clarity that lets the loss sink in and moves us toward a recalibration process. These episodes of sadness occur more frequently and with greater intensity the closer we are to the triggering event.

While emotions last minutes, mood, another affective state, lasts hours to days and is less intense and specific in content. A sad mood can be present much of the time after a significant loss. Emotions predispose to moods and vice versa.

Grief, on the other hand, is a complex and lengthy process that moves us from a place of loss to a new place with a new equilibrium without the lost object. While sadness is about fully acknowledging the loss, the grieving process is about getting beyond it. The bigger the loss, the bigger the hole in your life and the longer the grieving process. Grief is a multi-emotional process with people often experiencing a range of emotions, such as shock, anger, and fear in addition to sadness.

As I grappled with my sense of loss, I realized that understanding the grieving process was going to help me as I navigate this world now full of loss. Here are a few things we should all keep in mind.
 

A sense of mindful self-awareness

As we work through our grief, a mindful self-awareness can help us identify our emotions and see them as part of the grieving process. Simply anticipating emotions can lessen the impact of them when they come. As they come on, try to name the emotion, e.g., “I am so sad,” and feel the experience in the body. The sadness can be cathartic, and by focusing on the body and not the head, we can also drop the sometimes healthy, sometimes unhealthy rants and ruminations that can accompany these events. If we experience the emotions with mindful self-awareness, we can see our emotions as part of a healing, grieving process, and we will likely be able to handle them more gracefully.

In the days after the death of my nursing colleague, my sad mood would be interrupted with flares of anger triggered by thoughts of those not wearing masks or spreading misinformation. Moving my thoughts to the emotions, I would say to myself, “I am really angry, and I am angry because of these deaths.” I felt the recognition of the emotions helped me better ride the big waves on the grieving journey.

Counter to the thinking of the 20th century, research by George Bonanno at Columbia University found that the majority of bereavement is met with resilience. We will be sad, we might have moments of anger or denial or fear, but for most of us, despite the gravity of the loss, our innate resilience will lead about 50-80% of us to recover to near our baseline in months. It is nice to know we are not repressing things if we don’t pass through all the stages postulated by Elizabeth Kubler-Ross, the dominate paradigm in the field.¹

For those grieving, this idea of resilience being the norm can provide reassurance during tough moments. While our degree of resilience will depend on our loss and our circumstance, the work of Lucy Hone, PhD, suggests that resilience can be fostered. Many of the negative feelings we experience have a flip side we can seek out. We can be grateful for what remains and what the departed has left us with. We can aid in our grieving journey by using many of the resources available from UC Berkeley’s Greater Good in Action (https://ggia.berkeley.edu/).

While most grief is met with resilience, complicated grieving with persistent negative moods and emotions is common. We should consider seeking professional help if our emotions and pattern of thought continue to feel unhealthy.
 

Meaning and wisdom, not acceptance

Another change in our understanding of grief is this: Instead of “acceptance” being seen as the end result of grieving, meaning and wisdom are now recognized as the outcomes. Research has found that efforts to find meaning in loss facilitates the grieving process. As time passes and our sadness lessens, the loved one doesn’t leave us but stays with us as a better understanding of the beauty and complexity of life. The loss, through grieving, is transformed to wisdom that will guide us through future challenges and help us make sense of the world.

Last week, masked and robed and with an iPad in hand so the family could join the conversation, I was talking to Ms. B who is hospitalized with COVID-19. She said, “I just keep thinking, ‘Why is this happening to me? To all of us?’ And then I realized that it is a message from God that we need to do a better job of taking care of each other, and I suddenly felt a little better. What do you think, Dr. Hass?”

“Wow,” I said. “Thank you for sharing that. There is definitely some truth there. There is a lot to learn from the pandemic about how we care for each other. I need to keep that in mind when I start feeling down.”

So much is going on now: climate change, racial violence, frightening political dysfunction, and a global pandemic that has upended our daily routines and the economy. It is hard to keep track of all the loss and uncertainty. We might not know why feelings of sadness, anger and anxiety come on, but if we can meet these emotions with mindful equanimity, see them as part of our intrinsic healing process and keep in mind that our path will likely be towards one of wisdom and sense-making, we can better navigate these profoundly unsettling times.

Just as sadness is not grief, joy alone does not lead to happiness. A happy life comes as much from meaning as joy. While unbridled joy might be in short supply, our grief, our work as hospitalists with the suffering, and confronting the many problems our world faces gives us the opportunity to lead a meaningful life. If we couple this search for meaning with healthy habits that promote wellbeing, such as hugs, investing in relationships, and moving our body in the natural world, we can survive these crazy times and be wiser beings as a result of our experiences.
 

Dr. Hass is a hospitalist at Sutter East Bay Medical Group in Oakland, Calif. He is a member of the clinical faculty at the University of California, Berkeley-UC San Francisco joint medical program, and an adviser on health and health care at the Greater Good Science Center at UC Berkeley.

Reference

1. Bonanno GA, and Boerner K. The stage theory of grief. JAMA. 2007;297(24):2692-2694. doi:10.1001/jama.297.24.2693-a.

I arrived on the 6th floor nursing unit one day last fall to find halls abuzz with people. Something didn’t feel right, and then I a saw a nursing colleague with tears streaming down her face. My heart dropped. She looked up at me and said, “Dr Hass, K died last night.” She started to sob. I stood dumbfounded for a moment. We had lost a beloved coworker to COVID.

There has been a collective sense of grief in our country since the beginning of the COVID-19 pandemic as we have all been suffering losses: smiles, touch, in-person relationships, a “normal life.” But it went to another level for us at Alta Bates Summit Medical Center in Oakland, Calif., with the passing of a couple of our beloved teammates in the fall. Strong emotions triggered by these events caused me to pause and think: “What is grief? Is it another word for sadness? How do we work through it?”

What is the difference between sadness and grief? While related, they are temporally and functionally quite different. Sadness is an emotion, and like all emotions, we feel it in brief episodes. Those moments of profound sadness only last minutes at a time. Sadness leads to decreased physiological arousal, especially after crying. When less intense, the physiological slowing is thought to allow for some mental clarity that lets the loss sink in and moves us toward a recalibration process. These episodes of sadness occur more frequently and with greater intensity the closer we are to the triggering event.

While emotions last minutes, mood, another affective state, lasts hours to days and is less intense and specific in content. A sad mood can be present much of the time after a significant loss. Emotions predispose to moods and vice versa.

Grief, on the other hand, is a complex and lengthy process that moves us from a place of loss to a new place with a new equilibrium without the lost object. While sadness is about fully acknowledging the loss, the grieving process is about getting beyond it. The bigger the loss, the bigger the hole in your life and the longer the grieving process. Grief is a multi-emotional process with people often experiencing a range of emotions, such as shock, anger, and fear in addition to sadness.

As I grappled with my sense of loss, I realized that understanding the grieving process was going to help me as I navigate this world now full of loss. Here are a few things we should all keep in mind.
 

A sense of mindful self-awareness

As we work through our grief, a mindful self-awareness can help us identify our emotions and see them as part of the grieving process. Simply anticipating emotions can lessen the impact of them when they come. As they come on, try to name the emotion, e.g., “I am so sad,” and feel the experience in the body. The sadness can be cathartic, and by focusing on the body and not the head, we can also drop the sometimes healthy, sometimes unhealthy rants and ruminations that can accompany these events. If we experience the emotions with mindful self-awareness, we can see our emotions as part of a healing, grieving process, and we will likely be able to handle them more gracefully.

In the days after the death of my nursing colleague, my sad mood would be interrupted with flares of anger triggered by thoughts of those not wearing masks or spreading misinformation. Moving my thoughts to the emotions, I would say to myself, “I am really angry, and I am angry because of these deaths.” I felt the recognition of the emotions helped me better ride the big waves on the grieving journey.

Counter to the thinking of the 20th century, research by George Bonanno at Columbia University found that the majority of bereavement is met with resilience. We will be sad, we might have moments of anger or denial or fear, but for most of us, despite the gravity of the loss, our innate resilience will lead about 50-80% of us to recover to near our baseline in months. It is nice to know we are not repressing things if we don’t pass through all the stages postulated by Elizabeth Kubler-Ross, the dominate paradigm in the field.¹

For those grieving, this idea of resilience being the norm can provide reassurance during tough moments. While our degree of resilience will depend on our loss and our circumstance, the work of Lucy Hone, PhD, suggests that resilience can be fostered. Many of the negative feelings we experience have a flip side we can seek out. We can be grateful for what remains and what the departed has left us with. We can aid in our grieving journey by using many of the resources available from UC Berkeley’s Greater Good in Action (https://ggia.berkeley.edu/).

While most grief is met with resilience, complicated grieving with persistent negative moods and emotions is common. We should consider seeking professional help if our emotions and pattern of thought continue to feel unhealthy.
 

Meaning and wisdom, not acceptance

Another change in our understanding of grief is this: Instead of “acceptance” being seen as the end result of grieving, meaning and wisdom are now recognized as the outcomes. Research has found that efforts to find meaning in loss facilitates the grieving process. As time passes and our sadness lessens, the loved one doesn’t leave us but stays with us as a better understanding of the beauty and complexity of life. The loss, through grieving, is transformed to wisdom that will guide us through future challenges and help us make sense of the world.

Last week, masked and robed and with an iPad in hand so the family could join the conversation, I was talking to Ms. B who is hospitalized with COVID-19. She said, “I just keep thinking, ‘Why is this happening to me? To all of us?’ And then I realized that it is a message from God that we need to do a better job of taking care of each other, and I suddenly felt a little better. What do you think, Dr. Hass?”

“Wow,” I said. “Thank you for sharing that. There is definitely some truth there. There is a lot to learn from the pandemic about how we care for each other. I need to keep that in mind when I start feeling down.”

So much is going on now: climate change, racial violence, frightening political dysfunction, and a global pandemic that has upended our daily routines and the economy. It is hard to keep track of all the loss and uncertainty. We might not know why feelings of sadness, anger and anxiety come on, but if we can meet these emotions with mindful equanimity, see them as part of our intrinsic healing process and keep in mind that our path will likely be towards one of wisdom and sense-making, we can better navigate these profoundly unsettling times.

Just as sadness is not grief, joy alone does not lead to happiness. A happy life comes as much from meaning as joy. While unbridled joy might be in short supply, our grief, our work as hospitalists with the suffering, and confronting the many problems our world faces gives us the opportunity to lead a meaningful life. If we couple this search for meaning with healthy habits that promote wellbeing, such as hugs, investing in relationships, and moving our body in the natural world, we can survive these crazy times and be wiser beings as a result of our experiences.
 

Dr. Hass is a hospitalist at Sutter East Bay Medical Group in Oakland, Calif. He is a member of the clinical faculty at the University of California, Berkeley-UC San Francisco joint medical program, and an adviser on health and health care at the Greater Good Science Center at UC Berkeley.

Reference

1. Bonanno GA, and Boerner K. The stage theory of grief. JAMA. 2007;297(24):2692-2694. doi:10.1001/jama.297.24.2693-a.

I arrived on the 6th floor nursing unit one day last fall to find halls abuzz with people. Something didn’t feel right, and then I a saw a nursing colleague with tears streaming down her face. My heart dropped. She looked up at me and said, “Dr Hass, K died last night.” She started to sob. I stood dumbfounded for a moment. We had lost a beloved coworker to COVID.

There has been a collective sense of grief in our country since the beginning of the COVID-19 pandemic as we have all been suffering losses: smiles, touch, in-person relationships, a “normal life.” But it went to another level for us at Alta Bates Summit Medical Center in Oakland, Calif., with the passing of a couple of our beloved teammates in the fall. Strong emotions triggered by these events caused me to pause and think: “What is grief? Is it another word for sadness? How do we work through it?”

What is the difference between sadness and grief? While related, they are temporally and functionally quite different. Sadness is an emotion, and like all emotions, we feel it in brief episodes. Those moments of profound sadness only last minutes at a time. Sadness leads to decreased physiological arousal, especially after crying. When less intense, the physiological slowing is thought to allow for some mental clarity that lets the loss sink in and moves us toward a recalibration process. These episodes of sadness occur more frequently and with greater intensity the closer we are to the triggering event.

While emotions last minutes, mood, another affective state, lasts hours to days and is less intense and specific in content. A sad mood can be present much of the time after a significant loss. Emotions predispose to moods and vice versa.

Grief, on the other hand, is a complex and lengthy process that moves us from a place of loss to a new place with a new equilibrium without the lost object. While sadness is about fully acknowledging the loss, the grieving process is about getting beyond it. The bigger the loss, the bigger the hole in your life and the longer the grieving process. Grief is a multi-emotional process with people often experiencing a range of emotions, such as shock, anger, and fear in addition to sadness.

As I grappled with my sense of loss, I realized that understanding the grieving process was going to help me as I navigate this world now full of loss. Here are a few things we should all keep in mind.
 

A sense of mindful self-awareness

As we work through our grief, a mindful self-awareness can help us identify our emotions and see them as part of the grieving process. Simply anticipating emotions can lessen the impact of them when they come. As they come on, try to name the emotion, e.g., “I am so sad,” and feel the experience in the body. The sadness can be cathartic, and by focusing on the body and not the head, we can also drop the sometimes healthy, sometimes unhealthy rants and ruminations that can accompany these events. If we experience the emotions with mindful self-awareness, we can see our emotions as part of a healing, grieving process, and we will likely be able to handle them more gracefully.

In the days after the death of my nursing colleague, my sad mood would be interrupted with flares of anger triggered by thoughts of those not wearing masks or spreading misinformation. Moving my thoughts to the emotions, I would say to myself, “I am really angry, and I am angry because of these deaths.” I felt the recognition of the emotions helped me better ride the big waves on the grieving journey.

Counter to the thinking of the 20th century, research by George Bonanno at Columbia University found that the majority of bereavement is met with resilience. We will be sad, we might have moments of anger or denial or fear, but for most of us, despite the gravity of the loss, our innate resilience will lead about 50-80% of us to recover to near our baseline in months. It is nice to know we are not repressing things if we don’t pass through all the stages postulated by Elizabeth Kubler-Ross, the dominate paradigm in the field.¹

For those grieving, this idea of resilience being the norm can provide reassurance during tough moments. While our degree of resilience will depend on our loss and our circumstance, the work of Lucy Hone, PhD, suggests that resilience can be fostered. Many of the negative feelings we experience have a flip side we can seek out. We can be grateful for what remains and what the departed has left us with. We can aid in our grieving journey by using many of the resources available from UC Berkeley’s Greater Good in Action (https://ggia.berkeley.edu/).

While most grief is met with resilience, complicated grieving with persistent negative moods and emotions is common. We should consider seeking professional help if our emotions and pattern of thought continue to feel unhealthy.
 

Meaning and wisdom, not acceptance

Another change in our understanding of grief is this: Instead of “acceptance” being seen as the end result of grieving, meaning and wisdom are now recognized as the outcomes. Research has found that efforts to find meaning in loss facilitates the grieving process. As time passes and our sadness lessens, the loved one doesn’t leave us but stays with us as a better understanding of the beauty and complexity of life. The loss, through grieving, is transformed to wisdom that will guide us through future challenges and help us make sense of the world.

Last week, masked and robed and with an iPad in hand so the family could join the conversation, I was talking to Ms. B who is hospitalized with COVID-19. She said, “I just keep thinking, ‘Why is this happening to me? To all of us?’ And then I realized that it is a message from God that we need to do a better job of taking care of each other, and I suddenly felt a little better. What do you think, Dr. Hass?”

“Wow,” I said. “Thank you for sharing that. There is definitely some truth there. There is a lot to learn from the pandemic about how we care for each other. I need to keep that in mind when I start feeling down.”

So much is going on now: climate change, racial violence, frightening political dysfunction, and a global pandemic that has upended our daily routines and the economy. It is hard to keep track of all the loss and uncertainty. We might not know why feelings of sadness, anger and anxiety come on, but if we can meet these emotions with mindful equanimity, see them as part of our intrinsic healing process and keep in mind that our path will likely be towards one of wisdom and sense-making, we can better navigate these profoundly unsettling times.

Just as sadness is not grief, joy alone does not lead to happiness. A happy life comes as much from meaning as joy. While unbridled joy might be in short supply, our grief, our work as hospitalists with the suffering, and confronting the many problems our world faces gives us the opportunity to lead a meaningful life. If we couple this search for meaning with healthy habits that promote wellbeing, such as hugs, investing in relationships, and moving our body in the natural world, we can survive these crazy times and be wiser beings as a result of our experiences.
 

Dr. Hass is a hospitalist at Sutter East Bay Medical Group in Oakland, Calif. He is a member of the clinical faculty at the University of California, Berkeley-UC San Francisco joint medical program, and an adviser on health and health care at the Greater Good Science Center at UC Berkeley.

Reference

1. Bonanno GA, and Boerner K. The stage theory of grief. JAMA. 2007;297(24):2692-2694. doi:10.1001/jama.297.24.2693-a.

A 19-month-old boy comes to the office with a large firm erythematous swelling of his anterior left thigh that reaches from just below the inguinal crease to the patella. He got his routine immunizations 2 days prior to this visit including the fourth DTaP dose in his left thigh. Clinicians who care for children and who give routine immunizations occasionally see such an adverse effect following immunization (AEFI). These large local reactions have been described for many decades and occur after many vaccines.

What is extensive limb swelling (ELS)? ELS is defined as erythema/swelling crossing a joint or extending mostly joint to joint. It is a subset of large local AEFIs. ELS is generally firm and often erythematous with varying degrees of pain. ELS is now most frequent after pneumococcal conjugate vaccines (PCV) and DTaP, with a 1%-4% rate after DTaP boosters.^1-3 ELS and other large local swelling reactions occur at nearly any age.¹ And yet there is still much that is not known about their true pathogenesis. Likewise, there are no accurate predictors of which vaccinees will develop large inflammatory processes at or near the site of immunization.
 

ELS after standard vaccines

The largest report to date on AEFI of all ages, including ELS, covered 1990-2003.¹ Two upfront caveats are: This study evaluated ELS before PCVs were available, and in adults, repeat 23-valent pneumococcal polysaccharide vaccine was the most common cause of ELS in this study, comprising 45% of all adult ELS.

Considering all ages, ELS onset was nearly always greater than 1 hour and was less than 24 hours post vaccine in almost 75% of patients. However, for those aged under 2 years, onset in less than 24 hours was even more frequent (84%). Interestingly, concomitant fever occurred in less than 25% regardless of age. In adults, ELS after tetanus- and diphtheria-containing vaccines occurred mostly in women (75%); whereas for ELS under 8 years of age, males predominated (about 60%). Of note, tetanus- and diphtheria-containing vaccines were the most frequent ELS-inducing vaccines in children, that is, 75% aged under 8 years and 55% for those aged 8-17 years. Focusing on pediatric ELS after DTaP by dose, 33% were after the fourth, 31% after the fifth, 12% after the second, 10% after the first, and 3% after the third dose. In the case above, ELS was after the fourth dose.

Clinicians caring for children know how to manage ELS after DTaP or PCVs. They understand that ELS looks scary and is uncomfortable but is not dangerous and requires no specific treatment. Supportive management, that is, pain reliever, cool compresses, and TLC, are warranted. ELS is not a contraindication to subsequent immunization with the same vaccine. That said, large local reactions or ELS do occur with subsequent doses of that same vaccine at varying rates up to 66% of the time. Management is the same with repeat episodes, and no sequelae are expected. Supportive management only is standard unless one suspects a very rare Arthus reaction. If central necrosis occurs or swelling evolution/resolution is not per expectations, referral to a vaccine expert can sort out if it is an Arthus reaction, in which case, subsequent use of the same vaccine in not recommended.
 

ELS and SARS-CoV-2 vaccines

With SARS-CoV-2 vaccines now authorized for adolescents and expected in a few months for younger children, large local AEFI reactions related to pediatric SARS-CoV-2 vaccines are expected, given that “COVID arm” is now well described in adults.⁴ Overall, ELS/large local reactions have been reported more frequently with the Moderna than Pfizer mRNA vaccine.⁴ In the almost 42% of adults having ELS post first dose, repeat ELS post second dose often appears sooner but also resolves more quickly, with no known sequelae.⁵

Some biopsies have shown delayed-type hypersensitivity reactions (DTH) (superficial perivascular and perifollicular lymphocytic infiltrates with rare eosinophils and scattered mast cells),^6,7 while others show no DTH but these patients have findings of immediate hypersensitivity findings and negative skin testing to the vaccine.⁸ With regard to sex, Dutch ELS data in White adults reveal 90% occur in females – higher than the 75% female rate after standard vaccines.⁷ Onset of ELS data show that Pfizer mRNA vaccinees had onset on average at 38 hours (range, <1 hr to 12 days). Boston data mostly in White adults reveal later onset (median, 6 days; range, 2-12 days).⁴ In contrast, adults of color appear to have later onset (mean, 8 days; range, 4-14 days).⁹

In addition to the local swelling, patients had concurrent injection-site AEFIs of pain (65%), warmth (63%), and pruritus (26%), plus myalgia (51%), headache (48%), malaise (45%), fatigue (43%), chills (33%), arthralgia (30%), and fever (28%).⁷

What should we tell families about pediatric ELS before we give SARS-CoV-2 vaccines to children? Clinical pediatric SARS-CoV-2 vaccine trials are smaller “immunologic bridging” studies, not requiring proof of efficacy. So, the precise incidence of pediatric ELS (adult rate is estimated under 1/100,000) may not be known until months after general use. Nevertheless, part of our counseling of families will need to include ELS/large local reactions. Unless new data show otherwise, the spiel that clinicians have developed to counsel about the rare chance of ELS after routine vaccines should also be useful to inform families of the rare chance of ELS post SARS-CoV-2 vaccine.

The bottom line is that the management of pediatric ELS after SARS-CoV-2 vaccines should be the same as after standard vaccines. And remember, whether the reactions are DTH or not, neither immediate local injection-site reactions nor DTH reactions are contraindications to subsequent vaccination unless anaphylaxis or Arthus reaction is suspected.^10,11

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Woo EJ and the Vaccine Adverse Event Reporting System Working Group. Clin Infect Dis 2003;37:351-8.

2. Rennels MB et al. Pediatrics 2000;105:e12.

3. Huber BM, Goetschel P. J Pediatr. 2011;158:1033.

4. Blumenthal KG et al. N Engl J Med. 2021;384:1273-7.

5. McMahon DE et al. J Amer Acad Dermatol. 2021;85(1):46-55. 6. Johnston MS et al. JAMA Dermatol. 2021;157(6):716-20 .

7. ELS associated with the administration of Comirnaty®. WHO database Vigilyze (cited 2021 Feb 22). Available from https://vigilyze.who-umc.org/.

8. Baeck M et al. N Engl J Med. 2021 Jun. doi: 10.1056/NEJMc2104751.

9. Samarakoon U et al. N Eng J Med. 2021 Jun 9. doi: 10.1056/NEJMc2108620.

10. Kelso JM et al. J Allergy Clin Immunol. 2012;130:25-43.

11. Zafack JG et al. Pediatrics. 2017;140(3):e20163707.

A 19-month-old boy comes to the office with a large firm erythematous swelling of his anterior left thigh that reaches from just below the inguinal crease to the patella. He got his routine immunizations 2 days prior to this visit including the fourth DTaP dose in his left thigh. Clinicians who care for children and who give routine immunizations occasionally see such an adverse effect following immunization (AEFI). These large local reactions have been described for many decades and occur after many vaccines.

What is extensive limb swelling (ELS)? ELS is defined as erythema/swelling crossing a joint or extending mostly joint to joint. It is a subset of large local AEFIs. ELS is generally firm and often erythematous with varying degrees of pain. ELS is now most frequent after pneumococcal conjugate vaccines (PCV) and DTaP, with a 1%-4% rate after DTaP boosters.^1-3 ELS and other large local swelling reactions occur at nearly any age.¹ And yet there is still much that is not known about their true pathogenesis. Likewise, there are no accurate predictors of which vaccinees will develop large inflammatory processes at or near the site of immunization.
 

ELS after standard vaccines

The largest report to date on AEFI of all ages, including ELS, covered 1990-2003.¹ Two upfront caveats are: This study evaluated ELS before PCVs were available, and in adults, repeat 23-valent pneumococcal polysaccharide vaccine was the most common cause of ELS in this study, comprising 45% of all adult ELS.

Considering all ages, ELS onset was nearly always greater than 1 hour and was less than 24 hours post vaccine in almost 75% of patients. However, for those aged under 2 years, onset in less than 24 hours was even more frequent (84%). Interestingly, concomitant fever occurred in less than 25% regardless of age. In adults, ELS after tetanus- and diphtheria-containing vaccines occurred mostly in women (75%); whereas for ELS under 8 years of age, males predominated (about 60%). Of note, tetanus- and diphtheria-containing vaccines were the most frequent ELS-inducing vaccines in children, that is, 75% aged under 8 years and 55% for those aged 8-17 years. Focusing on pediatric ELS after DTaP by dose, 33% were after the fourth, 31% after the fifth, 12% after the second, 10% after the first, and 3% after the third dose. In the case above, ELS was after the fourth dose.

Clinicians caring for children know how to manage ELS after DTaP or PCVs. They understand that ELS looks scary and is uncomfortable but is not dangerous and requires no specific treatment. Supportive management, that is, pain reliever, cool compresses, and TLC, are warranted. ELS is not a contraindication to subsequent immunization with the same vaccine. That said, large local reactions or ELS do occur with subsequent doses of that same vaccine at varying rates up to 66% of the time. Management is the same with repeat episodes, and no sequelae are expected. Supportive management only is standard unless one suspects a very rare Arthus reaction. If central necrosis occurs or swelling evolution/resolution is not per expectations, referral to a vaccine expert can sort out if it is an Arthus reaction, in which case, subsequent use of the same vaccine in not recommended.
 

ELS and SARS-CoV-2 vaccines

With SARS-CoV-2 vaccines now authorized for adolescents and expected in a few months for younger children, large local AEFI reactions related to pediatric SARS-CoV-2 vaccines are expected, given that “COVID arm” is now well described in adults.⁴ Overall, ELS/large local reactions have been reported more frequently with the Moderna than Pfizer mRNA vaccine.⁴ In the almost 42% of adults having ELS post first dose, repeat ELS post second dose often appears sooner but also resolves more quickly, with no known sequelae.⁵

Some biopsies have shown delayed-type hypersensitivity reactions (DTH) (superficial perivascular and perifollicular lymphocytic infiltrates with rare eosinophils and scattered mast cells),^6,7 while others show no DTH but these patients have findings of immediate hypersensitivity findings and negative skin testing to the vaccine.⁸ With regard to sex, Dutch ELS data in White adults reveal 90% occur in females – higher than the 75% female rate after standard vaccines.⁷ Onset of ELS data show that Pfizer mRNA vaccinees had onset on average at 38 hours (range, <1 hr to 12 days). Boston data mostly in White adults reveal later onset (median, 6 days; range, 2-12 days).⁴ In contrast, adults of color appear to have later onset (mean, 8 days; range, 4-14 days).⁹

In addition to the local swelling, patients had concurrent injection-site AEFIs of pain (65%), warmth (63%), and pruritus (26%), plus myalgia (51%), headache (48%), malaise (45%), fatigue (43%), chills (33%), arthralgia (30%), and fever (28%).⁷

What should we tell families about pediatric ELS before we give SARS-CoV-2 vaccines to children? Clinical pediatric SARS-CoV-2 vaccine trials are smaller “immunologic bridging” studies, not requiring proof of efficacy. So, the precise incidence of pediatric ELS (adult rate is estimated under 1/100,000) may not be known until months after general use. Nevertheless, part of our counseling of families will need to include ELS/large local reactions. Unless new data show otherwise, the spiel that clinicians have developed to counsel about the rare chance of ELS after routine vaccines should also be useful to inform families of the rare chance of ELS post SARS-CoV-2 vaccine.

The bottom line is that the management of pediatric ELS after SARS-CoV-2 vaccines should be the same as after standard vaccines. And remember, whether the reactions are DTH or not, neither immediate local injection-site reactions nor DTH reactions are contraindications to subsequent vaccination unless anaphylaxis or Arthus reaction is suspected.^10,11

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Woo EJ and the Vaccine Adverse Event Reporting System Working Group. Clin Infect Dis 2003;37:351-8.

2. Rennels MB et al. Pediatrics 2000;105:e12.

3. Huber BM, Goetschel P. J Pediatr. 2011;158:1033.

4. Blumenthal KG et al. N Engl J Med. 2021;384:1273-7.

5. McMahon DE et al. J Amer Acad Dermatol. 2021;85(1):46-55. 6. Johnston MS et al. JAMA Dermatol. 2021;157(6):716-20 .

7. ELS associated with the administration of Comirnaty®. WHO database Vigilyze (cited 2021 Feb 22). Available from https://vigilyze.who-umc.org/.

8. Baeck M et al. N Engl J Med. 2021 Jun. doi: 10.1056/NEJMc2104751.

9. Samarakoon U et al. N Eng J Med. 2021 Jun 9. doi: 10.1056/NEJMc2108620.

10. Kelso JM et al. J Allergy Clin Immunol. 2012;130:25-43.

11. Zafack JG et al. Pediatrics. 2017;140(3):e20163707.

A 19-month-old boy comes to the office with a large firm erythematous swelling of his anterior left thigh that reaches from just below the inguinal crease to the patella. He got his routine immunizations 2 days prior to this visit including the fourth DTaP dose in his left thigh. Clinicians who care for children and who give routine immunizations occasionally see such an adverse effect following immunization (AEFI). These large local reactions have been described for many decades and occur after many vaccines.

What is extensive limb swelling (ELS)? ELS is defined as erythema/swelling crossing a joint or extending mostly joint to joint. It is a subset of large local AEFIs. ELS is generally firm and often erythematous with varying degrees of pain. ELS is now most frequent after pneumococcal conjugate vaccines (PCV) and DTaP, with a 1%-4% rate after DTaP boosters.^1-3 ELS and other large local swelling reactions occur at nearly any age.¹ And yet there is still much that is not known about their true pathogenesis. Likewise, there are no accurate predictors of which vaccinees will develop large inflammatory processes at or near the site of immunization.
 

ELS after standard vaccines

The largest report to date on AEFI of all ages, including ELS, covered 1990-2003.¹ Two upfront caveats are: This study evaluated ELS before PCVs were available, and in adults, repeat 23-valent pneumococcal polysaccharide vaccine was the most common cause of ELS in this study, comprising 45% of all adult ELS.

Considering all ages, ELS onset was nearly always greater than 1 hour and was less than 24 hours post vaccine in almost 75% of patients. However, for those aged under 2 years, onset in less than 24 hours was even more frequent (84%). Interestingly, concomitant fever occurred in less than 25% regardless of age. In adults, ELS after tetanus- and diphtheria-containing vaccines occurred mostly in women (75%); whereas for ELS under 8 years of age, males predominated (about 60%). Of note, tetanus- and diphtheria-containing vaccines were the most frequent ELS-inducing vaccines in children, that is, 75% aged under 8 years and 55% for those aged 8-17 years. Focusing on pediatric ELS after DTaP by dose, 33% were after the fourth, 31% after the fifth, 12% after the second, 10% after the first, and 3% after the third dose. In the case above, ELS was after the fourth dose.

Clinicians caring for children know how to manage ELS after DTaP or PCVs. They understand that ELS looks scary and is uncomfortable but is not dangerous and requires no specific treatment. Supportive management, that is, pain reliever, cool compresses, and TLC, are warranted. ELS is not a contraindication to subsequent immunization with the same vaccine. That said, large local reactions or ELS do occur with subsequent doses of that same vaccine at varying rates up to 66% of the time. Management is the same with repeat episodes, and no sequelae are expected. Supportive management only is standard unless one suspects a very rare Arthus reaction. If central necrosis occurs or swelling evolution/resolution is not per expectations, referral to a vaccine expert can sort out if it is an Arthus reaction, in which case, subsequent use of the same vaccine in not recommended.
 

ELS and SARS-CoV-2 vaccines

With SARS-CoV-2 vaccines now authorized for adolescents and expected in a few months for younger children, large local AEFI reactions related to pediatric SARS-CoV-2 vaccines are expected, given that “COVID arm” is now well described in adults.⁴ Overall, ELS/large local reactions have been reported more frequently with the Moderna than Pfizer mRNA vaccine.⁴ In the almost 42% of adults having ELS post first dose, repeat ELS post second dose often appears sooner but also resolves more quickly, with no known sequelae.⁵

Some biopsies have shown delayed-type hypersensitivity reactions (DTH) (superficial perivascular and perifollicular lymphocytic infiltrates with rare eosinophils and scattered mast cells),^6,7 while others show no DTH but these patients have findings of immediate hypersensitivity findings and negative skin testing to the vaccine.⁸ With regard to sex, Dutch ELS data in White adults reveal 90% occur in females – higher than the 75% female rate after standard vaccines.⁷ Onset of ELS data show that Pfizer mRNA vaccinees had onset on average at 38 hours (range, <1 hr to 12 days). Boston data mostly in White adults reveal later onset (median, 6 days; range, 2-12 days).⁴ In contrast, adults of color appear to have later onset (mean, 8 days; range, 4-14 days).⁹

In addition to the local swelling, patients had concurrent injection-site AEFIs of pain (65%), warmth (63%), and pruritus (26%), plus myalgia (51%), headache (48%), malaise (45%), fatigue (43%), chills (33%), arthralgia (30%), and fever (28%).⁷

What should we tell families about pediatric ELS before we give SARS-CoV-2 vaccines to children? Clinical pediatric SARS-CoV-2 vaccine trials are smaller “immunologic bridging” studies, not requiring proof of efficacy. So, the precise incidence of pediatric ELS (adult rate is estimated under 1/100,000) may not be known until months after general use. Nevertheless, part of our counseling of families will need to include ELS/large local reactions. Unless new data show otherwise, the spiel that clinicians have developed to counsel about the rare chance of ELS after routine vaccines should also be useful to inform families of the rare chance of ELS post SARS-CoV-2 vaccine.

The bottom line is that the management of pediatric ELS after SARS-CoV-2 vaccines should be the same as after standard vaccines. And remember, whether the reactions are DTH or not, neither immediate local injection-site reactions nor DTH reactions are contraindications to subsequent vaccination unless anaphylaxis or Arthus reaction is suspected.^10,11

Dr. Harrison is professor of pediatrics and pediatric infectious diseases at Children’s Mercy Hospitals and Clinics, Kansas City, Mo. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Woo EJ and the Vaccine Adverse Event Reporting System Working Group. Clin Infect Dis 2003;37:351-8.

2. Rennels MB et al. Pediatrics 2000;105:e12.

3. Huber BM, Goetschel P. J Pediatr. 2011;158:1033.

4. Blumenthal KG et al. N Engl J Med. 2021;384:1273-7.

5. McMahon DE et al. J Amer Acad Dermatol. 2021;85(1):46-55. 6. Johnston MS et al. JAMA Dermatol. 2021;157(6):716-20 .

7. ELS associated with the administration of Comirnaty®. WHO database Vigilyze (cited 2021 Feb 22). Available from https://vigilyze.who-umc.org/.

8. Baeck M et al. N Engl J Med. 2021 Jun. doi: 10.1056/NEJMc2104751.

9. Samarakoon U et al. N Eng J Med. 2021 Jun 9. doi: 10.1056/NEJMc2108620.

10. Kelso JM et al. J Allergy Clin Immunol. 2012;130:25-43.

11. Zafack JG et al. Pediatrics. 2017;140(3):e20163707.

Gradually, we are emerging from the chaos, isolation, and anxiety of COVID-19. As the Centers for Disease Control and Prevention adjusts its recommendations and vaccinations become more widely available, our communities are beginning to return to normalcy. We are encouraged to put aside our masks if vaccinated and rejoin society, to venture out with less hesitancy and anxiety. As family and friends reunite, memories of confusion, frustration, and fear are beginning to fade to black. Despite the prevailing belief that we should move on, look forward, and remember the past to safeguard our future, remnants of the pandemic remain.

shironosov/Getty Images

Unvaccinated individuals, notably children under the age of 12, are quite significant in number. The use of telehealth is now standard practice.

For several years, we were warned about the looming “mental health crisis.” The past year has demonstrated that a crisis no longer looms – it has arrived. Our patients can reveal the vulnerability COVID-19 has wrought – from the devastation of lives lost, supply shortages, loss of employment and financial stability – to a lack of access to computers and thereby, the risk of educational decline. Those factors, coupled with isolation and uncertainty about the future, have led to an influx of individuals with anxiety, depression, and other mood disorders seeking mental health treatment.
 

Doctors, others suffering

As result of a medical culture guided by the sacred oath to which care, compassion, and dedication held as true in ancient Greece as it does today, the focus centers on those around us – while signs of our own weariness are waved away as “a bad day.” Even though several support groups are readily available to offer a listening ear and mental health physicians who focus on the treatment of health care professionals are becoming more ubiquitous, the vestiges of past doctrine remain.

In this modern age of medical training, there is often as much sacrifice as there is attainment of knowledge. This philosophy is so ingrained that throughout training and practice one may come across colleagues experiencing an abundance of guilt when leave is needed for personal reasons. We are quick to recommend such steps for our patients, family, and friends, but hesitant to consider such for ourselves. Yet, of all the lessons this past year has wrought, the importance of mental health and self-care cannot be overstated. This raises the question: How do we incorporate wellness into our routines while navigating the complexity of medicine?

It is vital to accept our humanity as something not to repair, treat, or overcome but to understand. There is strength and power in vulnerability. If we do not perceive and validate this process within ourselves, how can we do so for others? In other words, the oxygen mask must be placed on us first before we can place it on anyone else – patients or otherwise.

Chiefly and above all else, the importance of identifying individual signs of stress is essential. Where do you hold tension? Are you prone to GI distress or headaches when taxed? Do you tend toward irritability, apathy, or exhaustion?

Once this is determined, it is important to assess your stress on a numerical scale, such as those used for pain. Are you a 5 or an 8? Finally, are there identifiable triggers or reliable alleviators? Is there a time of day or day of the week that is most difficult to manage? Can you anticipate potential stressors? Understanding your triggers, listening to your body, and practicing the language of self is the first step toward wellness.

Following introspection and observation, the next step is inventory. Take stock of your reserves. What replenishes? What depletes? What brings joy? What brings dread? Are there certain activities that mitigate stress? If so, how much time do they entail? Identify your number on a scale and associate that number with specific strategies or techniques. Remember that decompression for a 6 might be excessive for a 4. Furthermore, what is the duration of these feelings? Chronic stressors may incur gradual change verses sudden impact if acute. Through identifying personal signs, devising and using a scale, as well as escalating or de-escalating factors, individuals become more in tune with their bodies and therefore, more likely to intervene before burnout takes hold.

With this process well integrated, one can now consider stylized approaches for stress management. For example, those inclined toward mindfulness practices may find yoga, meditation, and relaxation exercises beneficial. Others may thrive on positive affirmations, gratitude, and thankfulness. While some might find relief in physical activity, be it strenuous or casual, the creative arts might appeal to those who find joy in painting, writing, or doing crafts. In addition, baking, reading, dancing, and/or listening to music might help lift stress.

Along with those discoveries, or in some cases, rediscoveries, basic needs such as dietary habits and nutrition, hydration, and sleep are vital toward emotional regulation, physiological homeostasis, and stress modulation. Remember HALT: Hungry, Angry, Lonely, Tired, Too hot, Too cold, Sad or Stressed. Those strategies are meant to guide self-care and highlight the importance of allowing time for self-awareness. Imagine yourself as if you are meeting a new patient. Establish rapport, identify symptoms, and explore options for treatment. When we give time to ourselves, we can give time more freely to others. With this in mind, try following the 5-minute wellness check that I formulated:

1. How am I feeling? What am I feeling?

2. Assess HALTS.

3. Identify the number on your scale.

4. Methods of quick de-escalation:

• Designate and schedule personal time.
• Write down daily goals.
• Repeat positive affirmations or write down words of gratitude.
• Use deep breathing exercises.
• Stretch or take a brief walk.
• Engage in mindfulness practices, such as meditation.

Once we develop a habit of monitoring, assessing, and practicing self-care, the process becomes more efficient and effective. Think of the way a seasoned attending can manage workflow with ease, compared with an intern. Recognizing signs and using these strategies routinely can become a quick daily measure of well-being.
 

Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.

Gradually, we are emerging from the chaos, isolation, and anxiety of COVID-19. As the Centers for Disease Control and Prevention adjusts its recommendations and vaccinations become more widely available, our communities are beginning to return to normalcy. We are encouraged to put aside our masks if vaccinated and rejoin society, to venture out with less hesitancy and anxiety. As family and friends reunite, memories of confusion, frustration, and fear are beginning to fade to black. Despite the prevailing belief that we should move on, look forward, and remember the past to safeguard our future, remnants of the pandemic remain.

shironosov/Getty Images

Unvaccinated individuals, notably children under the age of 12, are quite significant in number. The use of telehealth is now standard practice.

For several years, we were warned about the looming “mental health crisis.” The past year has demonstrated that a crisis no longer looms – it has arrived. Our patients can reveal the vulnerability COVID-19 has wrought – from the devastation of lives lost, supply shortages, loss of employment and financial stability – to a lack of access to computers and thereby, the risk of educational decline. Those factors, coupled with isolation and uncertainty about the future, have led to an influx of individuals with anxiety, depression, and other mood disorders seeking mental health treatment.
 

Doctors, others suffering

As result of a medical culture guided by the sacred oath to which care, compassion, and dedication held as true in ancient Greece as it does today, the focus centers on those around us – while signs of our own weariness are waved away as “a bad day.” Even though several support groups are readily available to offer a listening ear and mental health physicians who focus on the treatment of health care professionals are becoming more ubiquitous, the vestiges of past doctrine remain.

In this modern age of medical training, there is often as much sacrifice as there is attainment of knowledge. This philosophy is so ingrained that throughout training and practice one may come across colleagues experiencing an abundance of guilt when leave is needed for personal reasons. We are quick to recommend such steps for our patients, family, and friends, but hesitant to consider such for ourselves. Yet, of all the lessons this past year has wrought, the importance of mental health and self-care cannot be overstated. This raises the question: How do we incorporate wellness into our routines while navigating the complexity of medicine?

It is vital to accept our humanity as something not to repair, treat, or overcome but to understand. There is strength and power in vulnerability. If we do not perceive and validate this process within ourselves, how can we do so for others? In other words, the oxygen mask must be placed on us first before we can place it on anyone else – patients or otherwise.

Chiefly and above all else, the importance of identifying individual signs of stress is essential. Where do you hold tension? Are you prone to GI distress or headaches when taxed? Do you tend toward irritability, apathy, or exhaustion?

Once this is determined, it is important to assess your stress on a numerical scale, such as those used for pain. Are you a 5 or an 8? Finally, are there identifiable triggers or reliable alleviators? Is there a time of day or day of the week that is most difficult to manage? Can you anticipate potential stressors? Understanding your triggers, listening to your body, and practicing the language of self is the first step toward wellness.

Following introspection and observation, the next step is inventory. Take stock of your reserves. What replenishes? What depletes? What brings joy? What brings dread? Are there certain activities that mitigate stress? If so, how much time do they entail? Identify your number on a scale and associate that number with specific strategies or techniques. Remember that decompression for a 6 might be excessive for a 4. Furthermore, what is the duration of these feelings? Chronic stressors may incur gradual change verses sudden impact if acute. Through identifying personal signs, devising and using a scale, as well as escalating or de-escalating factors, individuals become more in tune with their bodies and therefore, more likely to intervene before burnout takes hold.

With this process well integrated, one can now consider stylized approaches for stress management. For example, those inclined toward mindfulness practices may find yoga, meditation, and relaxation exercises beneficial. Others may thrive on positive affirmations, gratitude, and thankfulness. While some might find relief in physical activity, be it strenuous or casual, the creative arts might appeal to those who find joy in painting, writing, or doing crafts. In addition, baking, reading, dancing, and/or listening to music might help lift stress.

Along with those discoveries, or in some cases, rediscoveries, basic needs such as dietary habits and nutrition, hydration, and sleep are vital toward emotional regulation, physiological homeostasis, and stress modulation. Remember HALT: Hungry, Angry, Lonely, Tired, Too hot, Too cold, Sad or Stressed. Those strategies are meant to guide self-care and highlight the importance of allowing time for self-awareness. Imagine yourself as if you are meeting a new patient. Establish rapport, identify symptoms, and explore options for treatment. When we give time to ourselves, we can give time more freely to others. With this in mind, try following the 5-minute wellness check that I formulated:

1. How am I feeling? What am I feeling?

2. Assess HALTS.

3. Identify the number on your scale.

4. Methods of quick de-escalation:

• Designate and schedule personal time.
• Write down daily goals.
• Repeat positive affirmations or write down words of gratitude.
• Use deep breathing exercises.
• Stretch or take a brief walk.
• Engage in mindfulness practices, such as meditation.

Once we develop a habit of monitoring, assessing, and practicing self-care, the process becomes more efficient and effective. Think of the way a seasoned attending can manage workflow with ease, compared with an intern. Recognizing signs and using these strategies routinely can become a quick daily measure of well-being.
 

Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.

Gradually, we are emerging from the chaos, isolation, and anxiety of COVID-19. As the Centers for Disease Control and Prevention adjusts its recommendations and vaccinations become more widely available, our communities are beginning to return to normalcy. We are encouraged to put aside our masks if vaccinated and rejoin society, to venture out with less hesitancy and anxiety. As family and friends reunite, memories of confusion, frustration, and fear are beginning to fade to black. Despite the prevailing belief that we should move on, look forward, and remember the past to safeguard our future, remnants of the pandemic remain.

shironosov/Getty Images

Unvaccinated individuals, notably children under the age of 12, are quite significant in number. The use of telehealth is now standard practice.

For several years, we were warned about the looming “mental health crisis.” The past year has demonstrated that a crisis no longer looms – it has arrived. Our patients can reveal the vulnerability COVID-19 has wrought – from the devastation of lives lost, supply shortages, loss of employment and financial stability – to a lack of access to computers and thereby, the risk of educational decline. Those factors, coupled with isolation and uncertainty about the future, have led to an influx of individuals with anxiety, depression, and other mood disorders seeking mental health treatment.
 

Doctors, others suffering

As result of a medical culture guided by the sacred oath to which care, compassion, and dedication held as true in ancient Greece as it does today, the focus centers on those around us – while signs of our own weariness are waved away as “a bad day.” Even though several support groups are readily available to offer a listening ear and mental health physicians who focus on the treatment of health care professionals are becoming more ubiquitous, the vestiges of past doctrine remain.

In this modern age of medical training, there is often as much sacrifice as there is attainment of knowledge. This philosophy is so ingrained that throughout training and practice one may come across colleagues experiencing an abundance of guilt when leave is needed for personal reasons. We are quick to recommend such steps for our patients, family, and friends, but hesitant to consider such for ourselves. Yet, of all the lessons this past year has wrought, the importance of mental health and self-care cannot be overstated. This raises the question: How do we incorporate wellness into our routines while navigating the complexity of medicine?

It is vital to accept our humanity as something not to repair, treat, or overcome but to understand. There is strength and power in vulnerability. If we do not perceive and validate this process within ourselves, how can we do so for others? In other words, the oxygen mask must be placed on us first before we can place it on anyone else – patients or otherwise.

Chiefly and above all else, the importance of identifying individual signs of stress is essential. Where do you hold tension? Are you prone to GI distress or headaches when taxed? Do you tend toward irritability, apathy, or exhaustion?

Once this is determined, it is important to assess your stress on a numerical scale, such as those used for pain. Are you a 5 or an 8? Finally, are there identifiable triggers or reliable alleviators? Is there a time of day or day of the week that is most difficult to manage? Can you anticipate potential stressors? Understanding your triggers, listening to your body, and practicing the language of self is the first step toward wellness.

Following introspection and observation, the next step is inventory. Take stock of your reserves. What replenishes? What depletes? What brings joy? What brings dread? Are there certain activities that mitigate stress? If so, how much time do they entail? Identify your number on a scale and associate that number with specific strategies or techniques. Remember that decompression for a 6 might be excessive for a 4. Furthermore, what is the duration of these feelings? Chronic stressors may incur gradual change verses sudden impact if acute. Through identifying personal signs, devising and using a scale, as well as escalating or de-escalating factors, individuals become more in tune with their bodies and therefore, more likely to intervene before burnout takes hold.

With this process well integrated, one can now consider stylized approaches for stress management. For example, those inclined toward mindfulness practices may find yoga, meditation, and relaxation exercises beneficial. Others may thrive on positive affirmations, gratitude, and thankfulness. While some might find relief in physical activity, be it strenuous or casual, the creative arts might appeal to those who find joy in painting, writing, or doing crafts. In addition, baking, reading, dancing, and/or listening to music might help lift stress.

Along with those discoveries, or in some cases, rediscoveries, basic needs such as dietary habits and nutrition, hydration, and sleep are vital toward emotional regulation, physiological homeostasis, and stress modulation. Remember HALT: Hungry, Angry, Lonely, Tired, Too hot, Too cold, Sad or Stressed. Those strategies are meant to guide self-care and highlight the importance of allowing time for self-awareness. Imagine yourself as if you are meeting a new patient. Establish rapport, identify symptoms, and explore options for treatment. When we give time to ourselves, we can give time more freely to others. With this in mind, try following the 5-minute wellness check that I formulated:

1. How am I feeling? What am I feeling?

2. Assess HALTS.

3. Identify the number on your scale.

4. Methods of quick de-escalation:

• Designate and schedule personal time.
• Write down daily goals.
• Repeat positive affirmations or write down words of gratitude.
• Use deep breathing exercises.
• Stretch or take a brief walk.
• Engage in mindfulness practices, such as meditation.

Once we develop a habit of monitoring, assessing, and practicing self-care, the process becomes more efficient and effective. Think of the way a seasoned attending can manage workflow with ease, compared with an intern. Recognizing signs and using these strategies routinely can become a quick daily measure of well-being.
 

Dr. Thomas is a board-certified adult psychiatrist with interests in chronic illness, women’s behavioral health, and minority mental health. She currently practices in North Kingstown and East Providence, R.I. Dr. Thomas has no conflicts of interest.

Cardiovascular disease is the leading cause of women’s death in the United States, accounting for 1 in every 5 female deaths per year according to the Centers for Disease Control and Prevention. Most risk factors for cardiovascular disease are modifiable. With a disease so prevalent in women’s health, obstetricians and gynecologists can assist patients in modifying these risk factors. This, however, is easier said than done.

One of the rate-limiting steps in assisting patients is the process of identifying an individual’s risk factors. This can be a time-consuming task in a women’s health appointment that is already busy with ObGyn-specific concerns, but technology can assist us.

Cardiovascular health app considerations

Many smartphone applications and websites are available that can alleviate the time constraints for identifying these individual modifiable risk factors. When evaluating cardiovascular risk factor apps for patients, keep these qualities (as outlined in the ACOG-recommended rubric) in mind: design, functionality, usefulness, and accuracy.

The patient-centered resources that assist women in identifying cardiovascular risk factors and that provide tools to positively impact these risk factors through lifestyle changes can help women achieve improved cardiovascular health. Recommendations include 1) manage blood pressure, 2) control cholesterol, 3) reduce blood sugar, 4) get active, 5) eat better, 6) lose weight, and 7) stop smoking.

National organizations’ smartphone apps guide the patient through a handful of questions about their current lifestyle, gender, age, and basic laboratory values. Their individual “heart health” results of these questions distribute the 7 risk factors to 3 categories based on the need to focus, improve, or celebrate. Through nonthreatening videos, patients can improve their scores themselves and bring the areas they need to focus, or improve, to their ObGyn’s attention for further assistance.

While adding one more task to an already busy practice can seem daunting, there are great technology resources that can be leveraged to successfully address this important health metric. By using the ACOG-recommended rubric and focusing on the app characteristics identified above, you can find one that works best for you and your patients and incorporate it into your practice today. ●

Cardiovascular disease is the leading cause of women’s death in the United States, accounting for 1 in every 5 female deaths per year according to the Centers for Disease Control and Prevention. Most risk factors for cardiovascular disease are modifiable. With a disease so prevalent in women’s health, obstetricians and gynecologists can assist patients in modifying these risk factors. This, however, is easier said than done.

One of the rate-limiting steps in assisting patients is the process of identifying an individual’s risk factors. This can be a time-consuming task in a women’s health appointment that is already busy with ObGyn-specific concerns, but technology can assist us.

Cardiovascular health app considerations

Many smartphone applications and websites are available that can alleviate the time constraints for identifying these individual modifiable risk factors. When evaluating cardiovascular risk factor apps for patients, keep these qualities (as outlined in the ACOG-recommended rubric) in mind: design, functionality, usefulness, and accuracy.

The patient-centered resources that assist women in identifying cardiovascular risk factors and that provide tools to positively impact these risk factors through lifestyle changes can help women achieve improved cardiovascular health. Recommendations include 1) manage blood pressure, 2) control cholesterol, 3) reduce blood sugar, 4) get active, 5) eat better, 6) lose weight, and 7) stop smoking.

National organizations’ smartphone apps guide the patient through a handful of questions about their current lifestyle, gender, age, and basic laboratory values. Their individual “heart health” results of these questions distribute the 7 risk factors to 3 categories based on the need to focus, improve, or celebrate. Through nonthreatening videos, patients can improve their scores themselves and bring the areas they need to focus, or improve, to their ObGyn’s attention for further assistance.

While adding one more task to an already busy practice can seem daunting, there are great technology resources that can be leveraged to successfully address this important health metric. By using the ACOG-recommended rubric and focusing on the app characteristics identified above, you can find one that works best for you and your patients and incorporate it into your practice today. ●

Cardiovascular disease is the leading cause of women’s death in the United States, accounting for 1 in every 5 female deaths per year according to the Centers for Disease Control and Prevention. Most risk factors for cardiovascular disease are modifiable. With a disease so prevalent in women’s health, obstetricians and gynecologists can assist patients in modifying these risk factors. This, however, is easier said than done.

One of the rate-limiting steps in assisting patients is the process of identifying an individual’s risk factors. This can be a time-consuming task in a women’s health appointment that is already busy with ObGyn-specific concerns, but technology can assist us.

Cardiovascular health app considerations

Many smartphone applications and websites are available that can alleviate the time constraints for identifying these individual modifiable risk factors. When evaluating cardiovascular risk factor apps for patients, keep these qualities (as outlined in the ACOG-recommended rubric) in mind: design, functionality, usefulness, and accuracy.

The patient-centered resources that assist women in identifying cardiovascular risk factors and that provide tools to positively impact these risk factors through lifestyle changes can help women achieve improved cardiovascular health. Recommendations include 1) manage blood pressure, 2) control cholesterol, 3) reduce blood sugar, 4) get active, 5) eat better, 6) lose weight, and 7) stop smoking.

National organizations’ smartphone apps guide the patient through a handful of questions about their current lifestyle, gender, age, and basic laboratory values. Their individual “heart health” results of these questions distribute the 7 risk factors to 3 categories based on the need to focus, improve, or celebrate. Through nonthreatening videos, patients can improve their scores themselves and bring the areas they need to focus, or improve, to their ObGyn’s attention for further assistance.

While adding one more task to an already busy practice can seem daunting, there are great technology resources that can be leveraged to successfully address this important health metric. By using the ACOG-recommended rubric and focusing on the app characteristics identified above, you can find one that works best for you and your patients and incorporate it into your practice today. ●

Last month we converged virtually for our annual conference, SHM Converge – the second time since the start of the coronavirus pandemic. We are thankful for innovations and advancements in technology that have allowed the world, including SHM, to continue connecting us all together. And yet, 18 months in, having forged new roads, experienced unique and life-changing events, we long for the in-person human connection that allows us to share a common experience. At a time of imperatives in our world – a global pandemic, systemic racism, and deep geopolitical divides – more than ever, we need to converge. Isolation only festers, deepening our divisions and conflicts.

In high school, I read Robert Frost’s poem “The Road Not Taken” and clung to the notion of diverging roads and choosing the road less traveled. Like most young people, my years since reading the poem were filled with attempts at forging new paths and experiencing great things – and yet, always feeling unaccomplished. Was Oscar Wilde right when he wrote: “Life imitates Art far more than Art imitates Life?” After all, these past 18 months, we have shared in the traumas of our times, and still, we remain isolated and alone. Our diverse experiences have been real, both tragic and heroic, from east to west, city to country, black to white, and red to blue.

At SHM, it’s time to converge and face the great challenges of our lifetime. A deadly pandemic continues to rage around the world, bringing unprecedented human suffering and loss of lives. In its wake, this pandemic also laid bare the ugly face of systemic racism, brought our deepest divisions to the surface – all threatening the very fabric of our society. This pandemic has been a stress test for health care systems, revealing our vulnerabilities and expanding the chasm of care between urban and rural communities, all in turn worsening our growing health disparities. This moment needs convergence to rekindle connection and solidarity.

Scholars do not interpret “The Road Not Taken” as a recommendation to take the road less traveled. Instead, it is a suggestion that the diverging roads lead to a common place having been “worn about the same” as they “equally lay.” It is true that our roads are unique and shape our lives, but so, too, does the destination and common place our roads lead us to. At that common place, during these taxing times, SHM enables hospitalists to tackle these great challenges.

For over 2 decades of dynamic changes in health care, SHM has been the workshop where hospitalists converged to sharpen clinical skills, improve quality and safety, develop acute care models inside and outside of hospitals, advocate for better health policy and blaze new trails. Though the issues evolved, and new ones emerge, today is no different.

Indeed, this is an historic time. This weighted moment meets us at the crossroads. A moment that demands synergy, cooperation, and creativity. A dynamic change to health care policy, advances in care innovation, renewed prioritization of public health, and rich national discourse on our social fabric; hospitalists are essential to every one of those conversations. SHM has evolved to meet our growing needs, equipping hospitalists with tools to engage at every level, and most importantly, enabled us to find our common place.

Where do we go now? I suggest we continue to take the roads not taken and at the destination, build the map of tomorrow, together.

Dr. Siy is division medical director, hospital specialties, in the departments of hospital medicine and community senior and palliative care at HealthPartners in Bloomington, Minn. He is the new president of SHM.

Last month we converged virtually for our annual conference, SHM Converge – the second time since the start of the coronavirus pandemic. We are thankful for innovations and advancements in technology that have allowed the world, including SHM, to continue connecting us all together. And yet, 18 months in, having forged new roads, experienced unique and life-changing events, we long for the in-person human connection that allows us to share a common experience. At a time of imperatives in our world – a global pandemic, systemic racism, and deep geopolitical divides – more than ever, we need to converge. Isolation only festers, deepening our divisions and conflicts.

In high school, I read Robert Frost’s poem “The Road Not Taken” and clung to the notion of diverging roads and choosing the road less traveled. Like most young people, my years since reading the poem were filled with attempts at forging new paths and experiencing great things – and yet, always feeling unaccomplished. Was Oscar Wilde right when he wrote: “Life imitates Art far more than Art imitates Life?” After all, these past 18 months, we have shared in the traumas of our times, and still, we remain isolated and alone. Our diverse experiences have been real, both tragic and heroic, from east to west, city to country, black to white, and red to blue.

At SHM, it’s time to converge and face the great challenges of our lifetime. A deadly pandemic continues to rage around the world, bringing unprecedented human suffering and loss of lives. In its wake, this pandemic also laid bare the ugly face of systemic racism, brought our deepest divisions to the surface – all threatening the very fabric of our society. This pandemic has been a stress test for health care systems, revealing our vulnerabilities and expanding the chasm of care between urban and rural communities, all in turn worsening our growing health disparities. This moment needs convergence to rekindle connection and solidarity.

Scholars do not interpret “The Road Not Taken” as a recommendation to take the road less traveled. Instead, it is a suggestion that the diverging roads lead to a common place having been “worn about the same” as they “equally lay.” It is true that our roads are unique and shape our lives, but so, too, does the destination and common place our roads lead us to. At that common place, during these taxing times, SHM enables hospitalists to tackle these great challenges.

For over 2 decades of dynamic changes in health care, SHM has been the workshop where hospitalists converged to sharpen clinical skills, improve quality and safety, develop acute care models inside and outside of hospitals, advocate for better health policy and blaze new trails. Though the issues evolved, and new ones emerge, today is no different.

Indeed, this is an historic time. This weighted moment meets us at the crossroads. A moment that demands synergy, cooperation, and creativity. A dynamic change to health care policy, advances in care innovation, renewed prioritization of public health, and rich national discourse on our social fabric; hospitalists are essential to every one of those conversations. SHM has evolved to meet our growing needs, equipping hospitalists with tools to engage at every level, and most importantly, enabled us to find our common place.

Where do we go now? I suggest we continue to take the roads not taken and at the destination, build the map of tomorrow, together.

Dr. Siy is division medical director, hospital specialties, in the departments of hospital medicine and community senior and palliative care at HealthPartners in Bloomington, Minn. He is the new president of SHM.

Last month we converged virtually for our annual conference, SHM Converge – the second time since the start of the coronavirus pandemic. We are thankful for innovations and advancements in technology that have allowed the world, including SHM, to continue connecting us all together. And yet, 18 months in, having forged new roads, experienced unique and life-changing events, we long for the in-person human connection that allows us to share a common experience. At a time of imperatives in our world – a global pandemic, systemic racism, and deep geopolitical divides – more than ever, we need to converge. Isolation only festers, deepening our divisions and conflicts.

In high school, I read Robert Frost’s poem “The Road Not Taken” and clung to the notion of diverging roads and choosing the road less traveled. Like most young people, my years since reading the poem were filled with attempts at forging new paths and experiencing great things – and yet, always feeling unaccomplished. Was Oscar Wilde right when he wrote: “Life imitates Art far more than Art imitates Life?” After all, these past 18 months, we have shared in the traumas of our times, and still, we remain isolated and alone. Our diverse experiences have been real, both tragic and heroic, from east to west, city to country, black to white, and red to blue.

At SHM, it’s time to converge and face the great challenges of our lifetime. A deadly pandemic continues to rage around the world, bringing unprecedented human suffering and loss of lives. In its wake, this pandemic also laid bare the ugly face of systemic racism, brought our deepest divisions to the surface – all threatening the very fabric of our society. This pandemic has been a stress test for health care systems, revealing our vulnerabilities and expanding the chasm of care between urban and rural communities, all in turn worsening our growing health disparities. This moment needs convergence to rekindle connection and solidarity.

Scholars do not interpret “The Road Not Taken” as a recommendation to take the road less traveled. Instead, it is a suggestion that the diverging roads lead to a common place having been “worn about the same” as they “equally lay.” It is true that our roads are unique and shape our lives, but so, too, does the destination and common place our roads lead us to. At that common place, during these taxing times, SHM enables hospitalists to tackle these great challenges.

For over 2 decades of dynamic changes in health care, SHM has been the workshop where hospitalists converged to sharpen clinical skills, improve quality and safety, develop acute care models inside and outside of hospitals, advocate for better health policy and blaze new trails. Though the issues evolved, and new ones emerge, today is no different.

Indeed, this is an historic time. This weighted moment meets us at the crossroads. A moment that demands synergy, cooperation, and creativity. A dynamic change to health care policy, advances in care innovation, renewed prioritization of public health, and rich national discourse on our social fabric; hospitalists are essential to every one of those conversations. SHM has evolved to meet our growing needs, equipping hospitalists with tools to engage at every level, and most importantly, enabled us to find our common place.

Where do we go now? I suggest we continue to take the roads not taken and at the destination, build the map of tomorrow, together.

Dr. Siy is division medical director, hospital specialties, in the departments of hospital medicine and community senior and palliative care at HealthPartners in Bloomington, Minn. He is the new president of SHM.