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Novel calculator predicts cancer risk in patients with CVD
Individualized 10-year and lifetime risks of cancer can now for the first time be estimated in patients with established cardiovascular disease, Cilie C. van ’t Klooster, MD, reported at the virtual annual congress of the European Society of Cardiology.
She and her coinvestigators have developed an easy-to-use predictive model that generates individualized risk estimates for total cancer, lung cancer, and colorectal cancer. The tool relies on nine readily available clinical variables: age, sex, smoking, weight, height, alcohol use, diabetes, antiplatelet drug use, and C-reactive protein level. The cancer risk calculator factors in an individual’s competing risk of death because of cardiovascular disease (CVD).
The risk calculator was developed using data on 7,280 patients with established CVD enrolled in the ongoing long-term Dutch UCC-SMART (Utrecht Cardiovascular Cohort – Second Manifestations of Arterial Disease) study, then independently validated in 9,322 patients in the double-blind CANTOS (Canakinumab Anti-Inflammatory Thrombosis Outcomes) trial, explained Dr. van ’t Klooster of Utrecht (the Netherlands) University.
Several other prediction models estimate the risk of a specific type of cancer, most commonly breast cancer or lung cancer. But the new Utrecht prediction tool is the first one to estimate total cancer risk. It’s also the first to apply specifically to patients with known CVD, thus filling an unmet need, because patients with established CVD are known to be on average at 19% increased risk of total cancer and 56% greater risk for lung cancer, compared with the general population. This is thought to be caused mainly by shared risk factors, including smoking, obesity, and low-grade systemic inflammation.
As the Utrecht/CANTOS analysis shows, however, that 19% increased relative risk for cancer in patients with CVD doesn’t tell the whole story. While the median lifetime and 10-year risks of total cancer in CANTOS were 26% and 10%, respectively, the individual patient risks for total cancer estimated using the Dutch prediction model ranged from 1% to 52% for lifetime and from 1% to 31% for 10-year risk. The same was true for lung cancer risk: median 5% lifetime and 2% 10-year risks, with individual patient risks ranging from 0% to 37% and from 0% to 24%. Likewise for colorectal cancer: a median 4% lifetime risk, ranging from 0% to 6%, and a median 2% risk over the next 10 years, with personalized risks ranging as high as 13% for lifetime risk and 6% for 10-year colorectal cancer risk.
The risk calculator performed “reasonably well,” according to Dr. van ’t Klooster. She pointed to a C-statistic of 0.74 for lung cancer, 0.63 for total cancer, and 0.64 for colorectal cancer. It’s possible the risk predictor’s performance could be further enhanced by incorporation of several potentially important factors that weren’t available in the UCC-SMART derivation cohort, including race, education level, and socioeconomic status, she added.
Potential applications for the risk calculator in clinical practice require further study, but include using the lifetime risk prediction for cancer as a motivational aid in conversations with patients about the importance of behavioral change in support of a healthier lifestyle. Also, a high predicted 10-year lung cancer risk could potentially be used to lower the threshold for a screening chest CT, resulting in earlier detection and treatment of lung cancer, Dr. van ’t Klooster noted.
In an interview, Bonnie Ky, MD, MSCE, praised the risk prediction study as rigorously executed, topical, and clinically significant.
“This paper signifies the overlap between our two disciplines of cancer and cardiovascular disease in terms of the risks that we face together when we care for this patient population,” said Dr. Ky, a cardiologist at the University of Pennsylvania, Philadelphia.
“Many of us in medicine believe in the importance of risk prediction: identifying who’s at high risk and doing everything we can to mitigate that risk. This paper speaks to that and moves us one step closer to accomplishing that aim,” added Dr. Ky, who is editor in chief of JACC: CardioOncology, which published the study simultaneously with Dr. van ’t Klooster’s presentation at ESC 2020. The paper provides direct access to the risk calculator.
Dr. van ’t Klooster reported having no financial conflicts regarding her study. UCC-SMART is funded by a Utrecht University grant, and CANTOS was funded by Novartis.
SOURCE: van ’t Klooster CC. ESC 2020 and JACC CardioOncol. 2020 Aug. doi: 10.1016/j.jaccao.2020.07.001.
Individualized 10-year and lifetime risks of cancer can now for the first time be estimated in patients with established cardiovascular disease, Cilie C. van ’t Klooster, MD, reported at the virtual annual congress of the European Society of Cardiology.
She and her coinvestigators have developed an easy-to-use predictive model that generates individualized risk estimates for total cancer, lung cancer, and colorectal cancer. The tool relies on nine readily available clinical variables: age, sex, smoking, weight, height, alcohol use, diabetes, antiplatelet drug use, and C-reactive protein level. The cancer risk calculator factors in an individual’s competing risk of death because of cardiovascular disease (CVD).
The risk calculator was developed using data on 7,280 patients with established CVD enrolled in the ongoing long-term Dutch UCC-SMART (Utrecht Cardiovascular Cohort – Second Manifestations of Arterial Disease) study, then independently validated in 9,322 patients in the double-blind CANTOS (Canakinumab Anti-Inflammatory Thrombosis Outcomes) trial, explained Dr. van ’t Klooster of Utrecht (the Netherlands) University.
Several other prediction models estimate the risk of a specific type of cancer, most commonly breast cancer or lung cancer. But the new Utrecht prediction tool is the first one to estimate total cancer risk. It’s also the first to apply specifically to patients with known CVD, thus filling an unmet need, because patients with established CVD are known to be on average at 19% increased risk of total cancer and 56% greater risk for lung cancer, compared with the general population. This is thought to be caused mainly by shared risk factors, including smoking, obesity, and low-grade systemic inflammation.
As the Utrecht/CANTOS analysis shows, however, that 19% increased relative risk for cancer in patients with CVD doesn’t tell the whole story. While the median lifetime and 10-year risks of total cancer in CANTOS were 26% and 10%, respectively, the individual patient risks for total cancer estimated using the Dutch prediction model ranged from 1% to 52% for lifetime and from 1% to 31% for 10-year risk. The same was true for lung cancer risk: median 5% lifetime and 2% 10-year risks, with individual patient risks ranging from 0% to 37% and from 0% to 24%. Likewise for colorectal cancer: a median 4% lifetime risk, ranging from 0% to 6%, and a median 2% risk over the next 10 years, with personalized risks ranging as high as 13% for lifetime risk and 6% for 10-year colorectal cancer risk.
The risk calculator performed “reasonably well,” according to Dr. van ’t Klooster. She pointed to a C-statistic of 0.74 for lung cancer, 0.63 for total cancer, and 0.64 for colorectal cancer. It’s possible the risk predictor’s performance could be further enhanced by incorporation of several potentially important factors that weren’t available in the UCC-SMART derivation cohort, including race, education level, and socioeconomic status, she added.
Potential applications for the risk calculator in clinical practice require further study, but include using the lifetime risk prediction for cancer as a motivational aid in conversations with patients about the importance of behavioral change in support of a healthier lifestyle. Also, a high predicted 10-year lung cancer risk could potentially be used to lower the threshold for a screening chest CT, resulting in earlier detection and treatment of lung cancer, Dr. van ’t Klooster noted.
In an interview, Bonnie Ky, MD, MSCE, praised the risk prediction study as rigorously executed, topical, and clinically significant.
“This paper signifies the overlap between our two disciplines of cancer and cardiovascular disease in terms of the risks that we face together when we care for this patient population,” said Dr. Ky, a cardiologist at the University of Pennsylvania, Philadelphia.
“Many of us in medicine believe in the importance of risk prediction: identifying who’s at high risk and doing everything we can to mitigate that risk. This paper speaks to that and moves us one step closer to accomplishing that aim,” added Dr. Ky, who is editor in chief of JACC: CardioOncology, which published the study simultaneously with Dr. van ’t Klooster’s presentation at ESC 2020. The paper provides direct access to the risk calculator.
Dr. van ’t Klooster reported having no financial conflicts regarding her study. UCC-SMART is funded by a Utrecht University grant, and CANTOS was funded by Novartis.
SOURCE: van ’t Klooster CC. ESC 2020 and JACC CardioOncol. 2020 Aug. doi: 10.1016/j.jaccao.2020.07.001.
Individualized 10-year and lifetime risks of cancer can now for the first time be estimated in patients with established cardiovascular disease, Cilie C. van ’t Klooster, MD, reported at the virtual annual congress of the European Society of Cardiology.
She and her coinvestigators have developed an easy-to-use predictive model that generates individualized risk estimates for total cancer, lung cancer, and colorectal cancer. The tool relies on nine readily available clinical variables: age, sex, smoking, weight, height, alcohol use, diabetes, antiplatelet drug use, and C-reactive protein level. The cancer risk calculator factors in an individual’s competing risk of death because of cardiovascular disease (CVD).
The risk calculator was developed using data on 7,280 patients with established CVD enrolled in the ongoing long-term Dutch UCC-SMART (Utrecht Cardiovascular Cohort – Second Manifestations of Arterial Disease) study, then independently validated in 9,322 patients in the double-blind CANTOS (Canakinumab Anti-Inflammatory Thrombosis Outcomes) trial, explained Dr. van ’t Klooster of Utrecht (the Netherlands) University.
Several other prediction models estimate the risk of a specific type of cancer, most commonly breast cancer or lung cancer. But the new Utrecht prediction tool is the first one to estimate total cancer risk. It’s also the first to apply specifically to patients with known CVD, thus filling an unmet need, because patients with established CVD are known to be on average at 19% increased risk of total cancer and 56% greater risk for lung cancer, compared with the general population. This is thought to be caused mainly by shared risk factors, including smoking, obesity, and low-grade systemic inflammation.
As the Utrecht/CANTOS analysis shows, however, that 19% increased relative risk for cancer in patients with CVD doesn’t tell the whole story. While the median lifetime and 10-year risks of total cancer in CANTOS were 26% and 10%, respectively, the individual patient risks for total cancer estimated using the Dutch prediction model ranged from 1% to 52% for lifetime and from 1% to 31% for 10-year risk. The same was true for lung cancer risk: median 5% lifetime and 2% 10-year risks, with individual patient risks ranging from 0% to 37% and from 0% to 24%. Likewise for colorectal cancer: a median 4% lifetime risk, ranging from 0% to 6%, and a median 2% risk over the next 10 years, with personalized risks ranging as high as 13% for lifetime risk and 6% for 10-year colorectal cancer risk.
The risk calculator performed “reasonably well,” according to Dr. van ’t Klooster. She pointed to a C-statistic of 0.74 for lung cancer, 0.63 for total cancer, and 0.64 for colorectal cancer. It’s possible the risk predictor’s performance could be further enhanced by incorporation of several potentially important factors that weren’t available in the UCC-SMART derivation cohort, including race, education level, and socioeconomic status, she added.
Potential applications for the risk calculator in clinical practice require further study, but include using the lifetime risk prediction for cancer as a motivational aid in conversations with patients about the importance of behavioral change in support of a healthier lifestyle. Also, a high predicted 10-year lung cancer risk could potentially be used to lower the threshold for a screening chest CT, resulting in earlier detection and treatment of lung cancer, Dr. van ’t Klooster noted.
In an interview, Bonnie Ky, MD, MSCE, praised the risk prediction study as rigorously executed, topical, and clinically significant.
“This paper signifies the overlap between our two disciplines of cancer and cardiovascular disease in terms of the risks that we face together when we care for this patient population,” said Dr. Ky, a cardiologist at the University of Pennsylvania, Philadelphia.
“Many of us in medicine believe in the importance of risk prediction: identifying who’s at high risk and doing everything we can to mitigate that risk. This paper speaks to that and moves us one step closer to accomplishing that aim,” added Dr. Ky, who is editor in chief of JACC: CardioOncology, which published the study simultaneously with Dr. van ’t Klooster’s presentation at ESC 2020. The paper provides direct access to the risk calculator.
Dr. van ’t Klooster reported having no financial conflicts regarding her study. UCC-SMART is funded by a Utrecht University grant, and CANTOS was funded by Novartis.
SOURCE: van ’t Klooster CC. ESC 2020 and JACC CardioOncol. 2020 Aug. doi: 10.1016/j.jaccao.2020.07.001.
FROM ESC CONGRESS 2020
In a time of two pandemics, a recommitment to work together
Overwhelmed. As if we weren’t already overwhelmed. For decades, hospitalists have been on the forefront of improving acute care amidst a rapidly changing environment. These last few decades have seen tremendous advances in medicine, technology, safety culture, innovations in payment models, transformation in business models, and a rising tide of health care policy. There was never a year we didn’t face major change … and adapt to it. Then 2020 came upon us.
This year, we adapt to more than a score and 4 years’ worth of change.
The two pandemics that have come upon us are like tsunamis. And many of us are drowning. We know of threats of pandemics: influenza, Ebola, and the like. But SARS-CoV-2 is new and like no other. We live in fear and isolation, each and every day learning new information and debunking others. We also know of racial injustice and racism, implicit or explicit in our nation, whether we live it or just read of it. George Floyd’s death in my hometown marked another tsunami, a great realization in our nation, and a great unmasking of our denial.
Yet our country is not united.
Hospital medicine is not immune to this disunity. At a time that we are all treading water, staying afloat in our own hospitals and communities, confronting these issues beyond our immediate spheres of influence is overwhelming. We are impacted by these pandemics, personally and professionally. And admittedly, we can be both victim and perpetrator.
In the face of a novel infectious agent, medicine responded quickly and pushed us beyond our limits. We have developed new infection prevention guidelines. We worked creatively to solve PPE shortages. We fashioned new work flows and new care models. We accelerated telehealth applications. We expanded the boundaries on home-based programs and reached out to vulnerable elderly in congregate living – an isolation no older person should have to endure. We cared for our colleagues, neighbors, and family members who fell ill, some who recovered, and sadly, some who fell. We developed best-practice guidelines, research protocols, created new order sets, note templates, and documentation standards. We flexed into EDs, ICUs, and field hospitals. Amidst the turmoil, we took pay cuts and saw colleagues go on furlough. And still, we mentored leaders in our schools, churches, synagogues, mosques, and civic communities.
And just when we thought we could endure no more, on May 25, we witnessed a black man in Minneapolis killed by a policeman’s knee. The same knee that divided Americans when black American athletes knelt to protest the injustice their people have endured for centuries. A knee that has been confused for insolence, when it was meant for justice ... yes, justice, for all. So, in early June, around the nation in support of black lives we also knelt, for almost 9 minutes.
This was the third time I cried during the pandemics.
For many of us, structural racism in America had finally been unmasked. The nation protested and rioted for weeks, and some communities have continued. Indeed, these two pandemics are still surging.
Side by side COVID-19 case conferences we lay transparent data demonstrating health disparities that we have tolerated for so long. We have vowed to resource equity work, and we opened dialogue, not only with patients and communities of color, but also with colleagues of color – some ready and some not yet ready to share and relive the traumas of their past and their present.
And still, we are not united.
While we physically mask to prevent the spread of COVID-19, we must make efforts to unmask the truths of SARS-CoV-2, the failings of our health system, the richness of our communities of color, and the injustice in the fabric of our society. More importantly, we must work together to create solutions. While we have diverse interests and priorities, at SHM, we can find common ground with kindred spirits, enhance the role of our specialty, and advance the health of our patients.
Let’s not be mistaken. These pandemics add to a growing list of interwoven issues in our society. In 2018, I wrote a piece on the role of hospitalists in addressing rural health disparities.1 According to the Sheps Center for Health Services Research, 129 rural hospitals have closed since 2010, closures that have accelerated with the COVID-19 pandemic.2 More than ever, we must stand above our inner and outer conflicts and be united to promote the health of our nation during these pandemics, because “all policy is health policy.”3
Most SHM presidents and president-elects come in with a platform, a priority for the specialty and for the society. This year, the platform has chosen us. For 20 years, I have witnessed SHM be a workshop for our members to address the pressing needs of our specialty and our patients. In 2020, we’ve continued to see SHM as a workshop for our members and a tour de force addressing these pandemics, from just in time publications of research and perspectives in the Journal of Hospital Medicine, to webinars and open access education in the Learning Portal, to advocacy on Capitol Hill. All of that work has been informed by you and for you. While there is still so much to do, we need not be overwhelmed when we do it together.
A score and 4 years ago, Robert Wachter, MD, and Lee Goldman, MD, dubbed us “hospitalists.” A year later, our shared workshop was born. Through one name change and now our first CEO transition from Larry Wellikson, MD, to Eric Howell, MD, SHM will continue to be where hospitalists both adapt and shape our nation through solutions that put an end to these pandemics. Let’s recommit to this work 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 president-elect of SHM.
Sources
1. Hardeman RR et al. Stolen Breaths. N Engl J Med. 2020 Jul 16;383:197-9.
2. Siy JC. Reviving Rural Health Care. The Hospitalist. 2018 Sep 24.
3. The Cecil G. Sheps Center For Health Services Research. Rural Hospital Closures. 2014. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/
Overwhelmed. As if we weren’t already overwhelmed. For decades, hospitalists have been on the forefront of improving acute care amidst a rapidly changing environment. These last few decades have seen tremendous advances in medicine, technology, safety culture, innovations in payment models, transformation in business models, and a rising tide of health care policy. There was never a year we didn’t face major change … and adapt to it. Then 2020 came upon us.
This year, we adapt to more than a score and 4 years’ worth of change.
The two pandemics that have come upon us are like tsunamis. And many of us are drowning. We know of threats of pandemics: influenza, Ebola, and the like. But SARS-CoV-2 is new and like no other. We live in fear and isolation, each and every day learning new information and debunking others. We also know of racial injustice and racism, implicit or explicit in our nation, whether we live it or just read of it. George Floyd’s death in my hometown marked another tsunami, a great realization in our nation, and a great unmasking of our denial.
Yet our country is not united.
Hospital medicine is not immune to this disunity. At a time that we are all treading water, staying afloat in our own hospitals and communities, confronting these issues beyond our immediate spheres of influence is overwhelming. We are impacted by these pandemics, personally and professionally. And admittedly, we can be both victim and perpetrator.
In the face of a novel infectious agent, medicine responded quickly and pushed us beyond our limits. We have developed new infection prevention guidelines. We worked creatively to solve PPE shortages. We fashioned new work flows and new care models. We accelerated telehealth applications. We expanded the boundaries on home-based programs and reached out to vulnerable elderly in congregate living – an isolation no older person should have to endure. We cared for our colleagues, neighbors, and family members who fell ill, some who recovered, and sadly, some who fell. We developed best-practice guidelines, research protocols, created new order sets, note templates, and documentation standards. We flexed into EDs, ICUs, and field hospitals. Amidst the turmoil, we took pay cuts and saw colleagues go on furlough. And still, we mentored leaders in our schools, churches, synagogues, mosques, and civic communities.
And just when we thought we could endure no more, on May 25, we witnessed a black man in Minneapolis killed by a policeman’s knee. The same knee that divided Americans when black American athletes knelt to protest the injustice their people have endured for centuries. A knee that has been confused for insolence, when it was meant for justice ... yes, justice, for all. So, in early June, around the nation in support of black lives we also knelt, for almost 9 minutes.
This was the third time I cried during the pandemics.
For many of us, structural racism in America had finally been unmasked. The nation protested and rioted for weeks, and some communities have continued. Indeed, these two pandemics are still surging.
Side by side COVID-19 case conferences we lay transparent data demonstrating health disparities that we have tolerated for so long. We have vowed to resource equity work, and we opened dialogue, not only with patients and communities of color, but also with colleagues of color – some ready and some not yet ready to share and relive the traumas of their past and their present.
And still, we are not united.
While we physically mask to prevent the spread of COVID-19, we must make efforts to unmask the truths of SARS-CoV-2, the failings of our health system, the richness of our communities of color, and the injustice in the fabric of our society. More importantly, we must work together to create solutions. While we have diverse interests and priorities, at SHM, we can find common ground with kindred spirits, enhance the role of our specialty, and advance the health of our patients.
Let’s not be mistaken. These pandemics add to a growing list of interwoven issues in our society. In 2018, I wrote a piece on the role of hospitalists in addressing rural health disparities.1 According to the Sheps Center for Health Services Research, 129 rural hospitals have closed since 2010, closures that have accelerated with the COVID-19 pandemic.2 More than ever, we must stand above our inner and outer conflicts and be united to promote the health of our nation during these pandemics, because “all policy is health policy.”3
Most SHM presidents and president-elects come in with a platform, a priority for the specialty and for the society. This year, the platform has chosen us. For 20 years, I have witnessed SHM be a workshop for our members to address the pressing needs of our specialty and our patients. In 2020, we’ve continued to see SHM as a workshop for our members and a tour de force addressing these pandemics, from just in time publications of research and perspectives in the Journal of Hospital Medicine, to webinars and open access education in the Learning Portal, to advocacy on Capitol Hill. All of that work has been informed by you and for you. While there is still so much to do, we need not be overwhelmed when we do it together.
A score and 4 years ago, Robert Wachter, MD, and Lee Goldman, MD, dubbed us “hospitalists.” A year later, our shared workshop was born. Through one name change and now our first CEO transition from Larry Wellikson, MD, to Eric Howell, MD, SHM will continue to be where hospitalists both adapt and shape our nation through solutions that put an end to these pandemics. Let’s recommit to this work 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 president-elect of SHM.
Sources
1. Hardeman RR et al. Stolen Breaths. N Engl J Med. 2020 Jul 16;383:197-9.
2. Siy JC. Reviving Rural Health Care. The Hospitalist. 2018 Sep 24.
3. The Cecil G. Sheps Center For Health Services Research. Rural Hospital Closures. 2014. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/
Overwhelmed. As if we weren’t already overwhelmed. For decades, hospitalists have been on the forefront of improving acute care amidst a rapidly changing environment. These last few decades have seen tremendous advances in medicine, technology, safety culture, innovations in payment models, transformation in business models, and a rising tide of health care policy. There was never a year we didn’t face major change … and adapt to it. Then 2020 came upon us.
This year, we adapt to more than a score and 4 years’ worth of change.
The two pandemics that have come upon us are like tsunamis. And many of us are drowning. We know of threats of pandemics: influenza, Ebola, and the like. But SARS-CoV-2 is new and like no other. We live in fear and isolation, each and every day learning new information and debunking others. We also know of racial injustice and racism, implicit or explicit in our nation, whether we live it or just read of it. George Floyd’s death in my hometown marked another tsunami, a great realization in our nation, and a great unmasking of our denial.
Yet our country is not united.
Hospital medicine is not immune to this disunity. At a time that we are all treading water, staying afloat in our own hospitals and communities, confronting these issues beyond our immediate spheres of influence is overwhelming. We are impacted by these pandemics, personally and professionally. And admittedly, we can be both victim and perpetrator.
In the face of a novel infectious agent, medicine responded quickly and pushed us beyond our limits. We have developed new infection prevention guidelines. We worked creatively to solve PPE shortages. We fashioned new work flows and new care models. We accelerated telehealth applications. We expanded the boundaries on home-based programs and reached out to vulnerable elderly in congregate living – an isolation no older person should have to endure. We cared for our colleagues, neighbors, and family members who fell ill, some who recovered, and sadly, some who fell. We developed best-practice guidelines, research protocols, created new order sets, note templates, and documentation standards. We flexed into EDs, ICUs, and field hospitals. Amidst the turmoil, we took pay cuts and saw colleagues go on furlough. And still, we mentored leaders in our schools, churches, synagogues, mosques, and civic communities.
And just when we thought we could endure no more, on May 25, we witnessed a black man in Minneapolis killed by a policeman’s knee. The same knee that divided Americans when black American athletes knelt to protest the injustice their people have endured for centuries. A knee that has been confused for insolence, when it was meant for justice ... yes, justice, for all. So, in early June, around the nation in support of black lives we also knelt, for almost 9 minutes.
This was the third time I cried during the pandemics.
For many of us, structural racism in America had finally been unmasked. The nation protested and rioted for weeks, and some communities have continued. Indeed, these two pandemics are still surging.
Side by side COVID-19 case conferences we lay transparent data demonstrating health disparities that we have tolerated for so long. We have vowed to resource equity work, and we opened dialogue, not only with patients and communities of color, but also with colleagues of color – some ready and some not yet ready to share and relive the traumas of their past and their present.
And still, we are not united.
While we physically mask to prevent the spread of COVID-19, we must make efforts to unmask the truths of SARS-CoV-2, the failings of our health system, the richness of our communities of color, and the injustice in the fabric of our society. More importantly, we must work together to create solutions. While we have diverse interests and priorities, at SHM, we can find common ground with kindred spirits, enhance the role of our specialty, and advance the health of our patients.
Let’s not be mistaken. These pandemics add to a growing list of interwoven issues in our society. In 2018, I wrote a piece on the role of hospitalists in addressing rural health disparities.1 According to the Sheps Center for Health Services Research, 129 rural hospitals have closed since 2010, closures that have accelerated with the COVID-19 pandemic.2 More than ever, we must stand above our inner and outer conflicts and be united to promote the health of our nation during these pandemics, because “all policy is health policy.”3
Most SHM presidents and president-elects come in with a platform, a priority for the specialty and for the society. This year, the platform has chosen us. For 20 years, I have witnessed SHM be a workshop for our members to address the pressing needs of our specialty and our patients. In 2020, we’ve continued to see SHM as a workshop for our members and a tour de force addressing these pandemics, from just in time publications of research and perspectives in the Journal of Hospital Medicine, to webinars and open access education in the Learning Portal, to advocacy on Capitol Hill. All of that work has been informed by you and for you. While there is still so much to do, we need not be overwhelmed when we do it together.
A score and 4 years ago, Robert Wachter, MD, and Lee Goldman, MD, dubbed us “hospitalists.” A year later, our shared workshop was born. Through one name change and now our first CEO transition from Larry Wellikson, MD, to Eric Howell, MD, SHM will continue to be where hospitalists both adapt and shape our nation through solutions that put an end to these pandemics. Let’s recommit to this work 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 president-elect of SHM.
Sources
1. Hardeman RR et al. Stolen Breaths. N Engl J Med. 2020 Jul 16;383:197-9.
2. Siy JC. Reviving Rural Health Care. The Hospitalist. 2018 Sep 24.
3. The Cecil G. Sheps Center For Health Services Research. Rural Hospital Closures. 2014. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/
Hospital medicine in a worldwide pandemic
SHM releases 2020 State of Hospital Medicine report
Every 2 years the Society of Hospital Medicine’s Practice Analysis Committee (PAC) surveys hospitalist groups nationwide on such key practice parameters as compensation, services provided, hours of work, and participation in leadership roles. Combined with compensation and productivity data on adult and pediatric hospitalists collected by the Medical Group Management Association, licensed to SHM for inclusion in this report, the State of Hospital Medicine (SoHM) report is the most authoritative and comprehensive source of information regarding contemporary hospitalist practice.
This year’s biannual report is based on survey responses submitted between Jan. 6 and Feb. 28, 2020, by 502 hospitalist group practices. That’s slightly fewer groups reporting data than for past surveys, but these groups were larger, on average, resulting in more full-time equivalents (FTEs) incorporated into the results, said PAC member Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. A total of 19.7% of the reporting groups provided pediatric hospital medicine data only, a much larger proportion than in past years.
The report is slated for publication in September, and SHM members can purchase it at a discount in print or electronic versions. “Our sense is that a lot of the fundamental information in the report will not have changed that much from 2018,” Ms. Flores said. “But these results convey the state of the field prior to the world-altering impact of the COVID-19 pandemic on hospitals of all sizes and settings.” How the hospital business and the practice of hospitalist groups have been and will be impacted by the pandemic, obviously, aren’t reflected in the data.
“We are finalizing a supplemental survey to go out to members at the end of the summer, specifically asking how COVID has impacted their hospitalist groups,” Ms. Flores said. These COVID-19 supplemental results will be released after the main report, sometime around the end of September. But results from the main survey, showing consistency in a number of key parameters, indicate that hospitalists continue to have a large and essential role in the U.S. health care system.
The leadership offered by hospitalists in the U.S. health care system’s response to surges of COVID-19 patients in many hospitals only underscores their importance, Ms. Flores added. “Hospitalists have definitely proven their worth. Imagine what the pandemic would have been like for hospitals if our specialty hadn’t been well-positioned to respond.” Hospitalists also showed an ability to adapt quickly to crises on the ground. But financial pressures imposed by the pandemic, combined with other trends previously in play, suggest that demands to cut costs and do more with less will be relentless as the field – and the world – tries to pull out of the pandemic crisis.
Compensation trends
One of the most eagerly anticipated findings in the SoHM is compensation. The median compensation for all adult hospitalists at the beginning of 2020 was $307,633 (with an average of $317,640), higher in the Midwest and lower in the East. The average base rate share of hospitalist compensation was 81.3%, with 11.6% based on productivity and 7.1% for performance – scored on such measures as patient satisfaction; accuracy and/or timeliness of documentation, billing, and coding; clinical processes; early morning discharge orders and times; and readmissions rates. A total of 46.6% of responding groups said they anticipated an increase in budgeted FTEs in the next year, while 51.2% expected to stay the same.
Subsidies or financial support for hospitalist practices break down in different ways, but in 2020 the median figure for financial support provided per adult hospitalist FTE was $198,750 (average, $201,760). This suggests that hospitals continue to see hospitalists as valued partners in health care, with useful knowledge of how the various components of the health care system work, said Tresa McNeal, MD, a hospitalist at Baylor Scott & White Medical Center, Temple, Tex., and a member of the PAC.
Scope of practice
Scope of practice for the hospitalist model continues to evolve, with increased demand for comanagement roles as other medical specialties are less inclined to visit patients in the hospital. Surgical comanagement accounted for much of that growth, but there were significant rates of comanagement for neurology, gastrointestinal and liver medicine, cardiology, and palliative care.
“Comanagement is a broad term without a single clear definition,” Ms. Flores said. “But when I talk about it, I refer to a broader array of hospitalists interacting with specialists.” The hospitalist‘s role could be as a consultant, or taking responsibility for admitting and attending.
Other identified roles played by hospitalists in adult-only groups included providing care for patients in the ICU (59.6% of reporting groups); primary responsibility for observation/short stay units, rapid response teams or code blue/cardiac arrest teams; cross-coverage for patients admitted without a hospitalist; and performing procedures such as vascular access, lumbar puncture, paracentesis, and thoracentesis. The hospitalist role’s in the ICU likely increased in many hospitals confronting COVID surges, Ms. Flores said.
The median number of shifts performed per year by a full-time hospitalist physician was 182.0 (average, 182.3), with 12 hours as the most common average duration for a shift in a daytime schedule. The 7-days-on/7-days-off model remained the most popular way to schedule adult hospitalists, at the same rate as in 2018. Backup coverage is another important issue for hospitalist groups, with 52.6% reporting no formal backup system. For those with a backup system, the highest proportion paid no additional compensation to the physician for being on the on-call schedule, but additional compensation was paid if called into the hospital.
Presence of nocturnists was reported by 71.9% of responding groups, slightly down from 2018, but increasing with the size of the group. “We continue to see a trend for dedicated nocturnists,” said Dr. McNeal. Hospitals see the benefits from the presence of a nocturnist, reflected in pay differentials or requiring fewer full-time shifts from nocturnists. It’s more consistent, higher quality of care delivered by people who are dedicated to that role.
In other findings from the survey, turnover in adult hospitalist groups is 10.9%t, which is up from 2018 but down from 2016. Unit-based assignment, also known as geographical rounding, was utilized by 42.7% of responding adult groups, with likelihood increasing with the size of the group. Unfilled positions were reported by 73.5% of groups, with an average of 11.2% of positions unfilled at the time of the survey.
The use of telemedicine in the hospital setting is evolving, likely considerably accelerated of necessity by the pandemic. “Many of us are using telemedicine with COVID patients in order to decrease clinicians’ time in the room, and to find a way to use a work force that has to be on leave,” Dr. McNeal said.
Nurse practitioners and physician assistants
The role for nurse practitioners and physician assistants in adult hospital medicine groups continues to increase, with 83.3% of groups reporting the presence of PAs and NPs, up from 77% in 2018. NPs/PAs are more likely in multistate hospitalist groups or integrated delivery system practices in hospitals/health systems.
The most common billing model for their professional services is a combination of independent billing by the PA/NP where allowed and shared services billing under a supervisory physician’s provider number – although 8.1% of groups report that their NPs/PAs didn’t generally provide billable services or submit bills for payment.
NPs and PAs spend one-fifth of their time, on average, on nonbillable, value-added work, including dedicated cross-coverage shifts, scheduling, patient assignments, nonbillable clinical work such as glycemic control, and quality improvement and performance improvement activities. “This is one example of the changing skill mix for the hospitalist group, helping the practice become more efficient,” Ms. Flores said.
NPs and PAs provide valuable services, Dr. McNeal added. “But it also takes some investment in time and training for them to be able to practice at the top of their license. My own hospitalist group has a training program for newly hired NPs/PAs. Everyone goes through this orientation for around 6-10 weeks, largely in a shadowing role starting out, until they gradually adjust to more clinical autonomy.”
This onboarding includes real-time evaluations and self-evaluations, and opportunities for conversations with experienced clinicians, working from a list of 30 “bread-and-butter” topics in hospital medicine, she noted.
Pediatric hospital medicine
The 2020 SoHM report includes a greater representation for pediatric hospital medicine, with a 200% increase in the proportion of reporting hospitalist groups that only take care of children. Thus, the pediatric data are more robust – and helpful – than in prior year surveys, said Sandra Gage, MD, SFHM, a pediatric hospitalist at Phoenix Children’s Hospital. Dr. Gage headed up the PAC’s expanded pediatric data initiative, with targeted outreach to pediatric groups to encourage their participation. She also convened a task force to come up with pediatric-specific questions that were more pertinent and user friendly.
One of the important questions for pediatric hospitalists involves scheduling – including variations in length of shifts – which can vary dramatically in pediatric HM groups. “This year we reported by number of hours expected for a clinical FTE, which should be more useful for group leaders,” Dr. Gage said. The median number of hours required per FTE from pediatric hospitalists was fairly consistent at 1,800 per year, with minor variations based on region and academic status.
“I don’t know that there’s anything too surprising in most of the data,” she said, but noted that SHM will now have a better pediatric baseline going forward. The survey also asked how many pediatric hospitalists were board certified in the new subspecialty of pediatric hospital medicine under the program launched last year by the American Board of Pediatrics. Its first qualifying exam was in November 2019. The average was 26%, but the variation between academic and nonacademic programs was unexpected, Dr. Gage said.
Pediatric hospitalists come from a variety of professional specialties besides pediatrics. Nearly half of all programs had at least one med/peds provider, while a smaller number of programs had providers from family medicine, internal medicine, emergency medicine, or palliative care, she noted. Half of pediatric hospitalists reported joining their practice directly out of residency. About 26% of pediatric hospital medicine (PHM) physicians were described as part time, and 34.3% of pediatric groups had the presence of an NP or PA.
“I think PHM evolved a little later than for adult hospitalists, but it has clearly come into its own as a field,” Dr. Gage said. In the COVID-19 crisis, some pediatric hospitalists have been asked to care for adult patients, which necessitated a flurry of activity to refresh their medical knowledge. Where pediatric units existed within the walls of adult hospitals and were temporarily closed for COVID, it’s not clear how many will reopen – perhaps ever.
Long-term impacts of the crisis
Some of the hospitalist group leaders Ms. Flores has spoken with in recent months point out that, while New York and some other early COVID-19 hot spots experienced a tremendous surge of patients and hospital crowding in March and April 2020, other hospitals didn’t see anywhere near the impact.
“For some, there was nothing going on with COVID where they were,” she said. Elective surgeries were widely canceled, but with no corresponding increase of COVID admissions; and with fewer patients showing up in EDs, some physicians found themselves idled.
What will be the longer-term impact of COVID-19? How will it change hospital medicine? “I definitely think things are going to change,” Ms. Flores said, speculating that licensing boards could find a way to make it easier for physicians to practice across state lines in response to crises like the pandemic. “Do we need to think at the national level about what we can do to create more surge capacity, to move people when and where they need to go in a crisis? Are there things SHM could do to help?”
Ms. Flores expects more hospital closures than followed the 2008-2009 economic recession, which likely will further drive the trend toward mergers and acquisitions – both of hospitalist groups and of hospitals.
“From the point of view of hospitals, financial pressures will only get worse, pressing us to reinvent how hospitalists work and how that could be made more efficient,” she said. “I hear hospitals saying: ‘We can’t sustain current trends.’ Meanwhile, specialists are saying they need more help from hospitalists, and frontline hospitalists are saying they’re already working too hard. What will we do about burnout?”
These competing trends were all headed toward a perfect storm even before the epidemic hit, Ms. Flores said. “The response will require some innovations we haven’t yet conceived of. Incremental change won’t get us where we need to be. But the hospitalist’s role will be more essential than ever.”
The 2020 data show that a lot of things have been fairly steady for hospitalists, said Thomas Frederickson, MD, a member of SHM’s PAC and a specialist in hospital medicine at CHI Health in Omaha, Neb. But one concern about this stability is that, while hospitalist compensation continues to go up, workload and by extension productivity remain relatively flat. “That has been a trend over the past decade, and some of us find it hard to make sense of that.”
Dr. Frederickson, too, sees a need for disruptive innovation. “I just wish I knew what that will be.” Perhaps, just as hospitalists played a large role in the quality revolution in hospitals over the past decade, maybe in the next decade they will come to play a large role in the right-sizing of hospital care in health systems, he said.
One other important finding: the number of hospitalists per group who play roles as physician leaders has also increased, with an average of 3.2 physicians per group in a formal leadership role (median of 2). But currently, 73% of the highest-ranking leaders in hospitalist groups are male, and they are disproportionally white. As reported in Medscape in 2019, 40% of working hospitalists are women and only 36% of hospitalists overall self-identified as White.1
“When you think of the demographics of actual working hospitalists, we could say the field of hospital medicine could and should do better in creating opportunities for diversity in leadership roles,” Ms. Flores said.
Reference
1. Martin KL. Hospitalist Compensation Report for 2019. Medscape. 2019 Jun 5. https://www.medscape.com/slideshow/2019-compensation-hospitalist-6011429#3.
SHM releases 2020 State of Hospital Medicine report
SHM releases 2020 State of Hospital Medicine report
Every 2 years the Society of Hospital Medicine’s Practice Analysis Committee (PAC) surveys hospitalist groups nationwide on such key practice parameters as compensation, services provided, hours of work, and participation in leadership roles. Combined with compensation and productivity data on adult and pediatric hospitalists collected by the Medical Group Management Association, licensed to SHM for inclusion in this report, the State of Hospital Medicine (SoHM) report is the most authoritative and comprehensive source of information regarding contemporary hospitalist practice.
This year’s biannual report is based on survey responses submitted between Jan. 6 and Feb. 28, 2020, by 502 hospitalist group practices. That’s slightly fewer groups reporting data than for past surveys, but these groups were larger, on average, resulting in more full-time equivalents (FTEs) incorporated into the results, said PAC member Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. A total of 19.7% of the reporting groups provided pediatric hospital medicine data only, a much larger proportion than in past years.
The report is slated for publication in September, and SHM members can purchase it at a discount in print or electronic versions. “Our sense is that a lot of the fundamental information in the report will not have changed that much from 2018,” Ms. Flores said. “But these results convey the state of the field prior to the world-altering impact of the COVID-19 pandemic on hospitals of all sizes and settings.” How the hospital business and the practice of hospitalist groups have been and will be impacted by the pandemic, obviously, aren’t reflected in the data.
“We are finalizing a supplemental survey to go out to members at the end of the summer, specifically asking how COVID has impacted their hospitalist groups,” Ms. Flores said. These COVID-19 supplemental results will be released after the main report, sometime around the end of September. But results from the main survey, showing consistency in a number of key parameters, indicate that hospitalists continue to have a large and essential role in the U.S. health care system.
The leadership offered by hospitalists in the U.S. health care system’s response to surges of COVID-19 patients in many hospitals only underscores their importance, Ms. Flores added. “Hospitalists have definitely proven their worth. Imagine what the pandemic would have been like for hospitals if our specialty hadn’t been well-positioned to respond.” Hospitalists also showed an ability to adapt quickly to crises on the ground. But financial pressures imposed by the pandemic, combined with other trends previously in play, suggest that demands to cut costs and do more with less will be relentless as the field – and the world – tries to pull out of the pandemic crisis.
Compensation trends
One of the most eagerly anticipated findings in the SoHM is compensation. The median compensation for all adult hospitalists at the beginning of 2020 was $307,633 (with an average of $317,640), higher in the Midwest and lower in the East. The average base rate share of hospitalist compensation was 81.3%, with 11.6% based on productivity and 7.1% for performance – scored on such measures as patient satisfaction; accuracy and/or timeliness of documentation, billing, and coding; clinical processes; early morning discharge orders and times; and readmissions rates. A total of 46.6% of responding groups said they anticipated an increase in budgeted FTEs in the next year, while 51.2% expected to stay the same.
Subsidies or financial support for hospitalist practices break down in different ways, but in 2020 the median figure for financial support provided per adult hospitalist FTE was $198,750 (average, $201,760). This suggests that hospitals continue to see hospitalists as valued partners in health care, with useful knowledge of how the various components of the health care system work, said Tresa McNeal, MD, a hospitalist at Baylor Scott & White Medical Center, Temple, Tex., and a member of the PAC.
Scope of practice
Scope of practice for the hospitalist model continues to evolve, with increased demand for comanagement roles as other medical specialties are less inclined to visit patients in the hospital. Surgical comanagement accounted for much of that growth, but there were significant rates of comanagement for neurology, gastrointestinal and liver medicine, cardiology, and palliative care.
“Comanagement is a broad term without a single clear definition,” Ms. Flores said. “But when I talk about it, I refer to a broader array of hospitalists interacting with specialists.” The hospitalist‘s role could be as a consultant, or taking responsibility for admitting and attending.
Other identified roles played by hospitalists in adult-only groups included providing care for patients in the ICU (59.6% of reporting groups); primary responsibility for observation/short stay units, rapid response teams or code blue/cardiac arrest teams; cross-coverage for patients admitted without a hospitalist; and performing procedures such as vascular access, lumbar puncture, paracentesis, and thoracentesis. The hospitalist role’s in the ICU likely increased in many hospitals confronting COVID surges, Ms. Flores said.
The median number of shifts performed per year by a full-time hospitalist physician was 182.0 (average, 182.3), with 12 hours as the most common average duration for a shift in a daytime schedule. The 7-days-on/7-days-off model remained the most popular way to schedule adult hospitalists, at the same rate as in 2018. Backup coverage is another important issue for hospitalist groups, with 52.6% reporting no formal backup system. For those with a backup system, the highest proportion paid no additional compensation to the physician for being on the on-call schedule, but additional compensation was paid if called into the hospital.
Presence of nocturnists was reported by 71.9% of responding groups, slightly down from 2018, but increasing with the size of the group. “We continue to see a trend for dedicated nocturnists,” said Dr. McNeal. Hospitals see the benefits from the presence of a nocturnist, reflected in pay differentials or requiring fewer full-time shifts from nocturnists. It’s more consistent, higher quality of care delivered by people who are dedicated to that role.
In other findings from the survey, turnover in adult hospitalist groups is 10.9%t, which is up from 2018 but down from 2016. Unit-based assignment, also known as geographical rounding, was utilized by 42.7% of responding adult groups, with likelihood increasing with the size of the group. Unfilled positions were reported by 73.5% of groups, with an average of 11.2% of positions unfilled at the time of the survey.
The use of telemedicine in the hospital setting is evolving, likely considerably accelerated of necessity by the pandemic. “Many of us are using telemedicine with COVID patients in order to decrease clinicians’ time in the room, and to find a way to use a work force that has to be on leave,” Dr. McNeal said.
Nurse practitioners and physician assistants
The role for nurse practitioners and physician assistants in adult hospital medicine groups continues to increase, with 83.3% of groups reporting the presence of PAs and NPs, up from 77% in 2018. NPs/PAs are more likely in multistate hospitalist groups or integrated delivery system practices in hospitals/health systems.
The most common billing model for their professional services is a combination of independent billing by the PA/NP where allowed and shared services billing under a supervisory physician’s provider number – although 8.1% of groups report that their NPs/PAs didn’t generally provide billable services or submit bills for payment.
NPs and PAs spend one-fifth of their time, on average, on nonbillable, value-added work, including dedicated cross-coverage shifts, scheduling, patient assignments, nonbillable clinical work such as glycemic control, and quality improvement and performance improvement activities. “This is one example of the changing skill mix for the hospitalist group, helping the practice become more efficient,” Ms. Flores said.
NPs and PAs provide valuable services, Dr. McNeal added. “But it also takes some investment in time and training for them to be able to practice at the top of their license. My own hospitalist group has a training program for newly hired NPs/PAs. Everyone goes through this orientation for around 6-10 weeks, largely in a shadowing role starting out, until they gradually adjust to more clinical autonomy.”
This onboarding includes real-time evaluations and self-evaluations, and opportunities for conversations with experienced clinicians, working from a list of 30 “bread-and-butter” topics in hospital medicine, she noted.
Pediatric hospital medicine
The 2020 SoHM report includes a greater representation for pediatric hospital medicine, with a 200% increase in the proportion of reporting hospitalist groups that only take care of children. Thus, the pediatric data are more robust – and helpful – than in prior year surveys, said Sandra Gage, MD, SFHM, a pediatric hospitalist at Phoenix Children’s Hospital. Dr. Gage headed up the PAC’s expanded pediatric data initiative, with targeted outreach to pediatric groups to encourage their participation. She also convened a task force to come up with pediatric-specific questions that were more pertinent and user friendly.
One of the important questions for pediatric hospitalists involves scheduling – including variations in length of shifts – which can vary dramatically in pediatric HM groups. “This year we reported by number of hours expected for a clinical FTE, which should be more useful for group leaders,” Dr. Gage said. The median number of hours required per FTE from pediatric hospitalists was fairly consistent at 1,800 per year, with minor variations based on region and academic status.
“I don’t know that there’s anything too surprising in most of the data,” she said, but noted that SHM will now have a better pediatric baseline going forward. The survey also asked how many pediatric hospitalists were board certified in the new subspecialty of pediatric hospital medicine under the program launched last year by the American Board of Pediatrics. Its first qualifying exam was in November 2019. The average was 26%, but the variation between academic and nonacademic programs was unexpected, Dr. Gage said.
Pediatric hospitalists come from a variety of professional specialties besides pediatrics. Nearly half of all programs had at least one med/peds provider, while a smaller number of programs had providers from family medicine, internal medicine, emergency medicine, or palliative care, she noted. Half of pediatric hospitalists reported joining their practice directly out of residency. About 26% of pediatric hospital medicine (PHM) physicians were described as part time, and 34.3% of pediatric groups had the presence of an NP or PA.
“I think PHM evolved a little later than for adult hospitalists, but it has clearly come into its own as a field,” Dr. Gage said. In the COVID-19 crisis, some pediatric hospitalists have been asked to care for adult patients, which necessitated a flurry of activity to refresh their medical knowledge. Where pediatric units existed within the walls of adult hospitals and were temporarily closed for COVID, it’s not clear how many will reopen – perhaps ever.
Long-term impacts of the crisis
Some of the hospitalist group leaders Ms. Flores has spoken with in recent months point out that, while New York and some other early COVID-19 hot spots experienced a tremendous surge of patients and hospital crowding in March and April 2020, other hospitals didn’t see anywhere near the impact.
“For some, there was nothing going on with COVID where they were,” she said. Elective surgeries were widely canceled, but with no corresponding increase of COVID admissions; and with fewer patients showing up in EDs, some physicians found themselves idled.
What will be the longer-term impact of COVID-19? How will it change hospital medicine? “I definitely think things are going to change,” Ms. Flores said, speculating that licensing boards could find a way to make it easier for physicians to practice across state lines in response to crises like the pandemic. “Do we need to think at the national level about what we can do to create more surge capacity, to move people when and where they need to go in a crisis? Are there things SHM could do to help?”
Ms. Flores expects more hospital closures than followed the 2008-2009 economic recession, which likely will further drive the trend toward mergers and acquisitions – both of hospitalist groups and of hospitals.
“From the point of view of hospitals, financial pressures will only get worse, pressing us to reinvent how hospitalists work and how that could be made more efficient,” she said. “I hear hospitals saying: ‘We can’t sustain current trends.’ Meanwhile, specialists are saying they need more help from hospitalists, and frontline hospitalists are saying they’re already working too hard. What will we do about burnout?”
These competing trends were all headed toward a perfect storm even before the epidemic hit, Ms. Flores said. “The response will require some innovations we haven’t yet conceived of. Incremental change won’t get us where we need to be. But the hospitalist’s role will be more essential than ever.”
The 2020 data show that a lot of things have been fairly steady for hospitalists, said Thomas Frederickson, MD, a member of SHM’s PAC and a specialist in hospital medicine at CHI Health in Omaha, Neb. But one concern about this stability is that, while hospitalist compensation continues to go up, workload and by extension productivity remain relatively flat. “That has been a trend over the past decade, and some of us find it hard to make sense of that.”
Dr. Frederickson, too, sees a need for disruptive innovation. “I just wish I knew what that will be.” Perhaps, just as hospitalists played a large role in the quality revolution in hospitals over the past decade, maybe in the next decade they will come to play a large role in the right-sizing of hospital care in health systems, he said.
One other important finding: the number of hospitalists per group who play roles as physician leaders has also increased, with an average of 3.2 physicians per group in a formal leadership role (median of 2). But currently, 73% of the highest-ranking leaders in hospitalist groups are male, and they are disproportionally white. As reported in Medscape in 2019, 40% of working hospitalists are women and only 36% of hospitalists overall self-identified as White.1
“When you think of the demographics of actual working hospitalists, we could say the field of hospital medicine could and should do better in creating opportunities for diversity in leadership roles,” Ms. Flores said.
Reference
1. Martin KL. Hospitalist Compensation Report for 2019. Medscape. 2019 Jun 5. https://www.medscape.com/slideshow/2019-compensation-hospitalist-6011429#3.
Every 2 years the Society of Hospital Medicine’s Practice Analysis Committee (PAC) surveys hospitalist groups nationwide on such key practice parameters as compensation, services provided, hours of work, and participation in leadership roles. Combined with compensation and productivity data on adult and pediatric hospitalists collected by the Medical Group Management Association, licensed to SHM for inclusion in this report, the State of Hospital Medicine (SoHM) report is the most authoritative and comprehensive source of information regarding contemporary hospitalist practice.
This year’s biannual report is based on survey responses submitted between Jan. 6 and Feb. 28, 2020, by 502 hospitalist group practices. That’s slightly fewer groups reporting data than for past surveys, but these groups were larger, on average, resulting in more full-time equivalents (FTEs) incorporated into the results, said PAC member Leslie Flores, MHA, SFHM, of Nelson Flores Hospital Medicine Consultants. A total of 19.7% of the reporting groups provided pediatric hospital medicine data only, a much larger proportion than in past years.
The report is slated for publication in September, and SHM members can purchase it at a discount in print or electronic versions. “Our sense is that a lot of the fundamental information in the report will not have changed that much from 2018,” Ms. Flores said. “But these results convey the state of the field prior to the world-altering impact of the COVID-19 pandemic on hospitals of all sizes and settings.” How the hospital business and the practice of hospitalist groups have been and will be impacted by the pandemic, obviously, aren’t reflected in the data.
“We are finalizing a supplemental survey to go out to members at the end of the summer, specifically asking how COVID has impacted their hospitalist groups,” Ms. Flores said. These COVID-19 supplemental results will be released after the main report, sometime around the end of September. But results from the main survey, showing consistency in a number of key parameters, indicate that hospitalists continue to have a large and essential role in the U.S. health care system.
The leadership offered by hospitalists in the U.S. health care system’s response to surges of COVID-19 patients in many hospitals only underscores their importance, Ms. Flores added. “Hospitalists have definitely proven their worth. Imagine what the pandemic would have been like for hospitals if our specialty hadn’t been well-positioned to respond.” Hospitalists also showed an ability to adapt quickly to crises on the ground. But financial pressures imposed by the pandemic, combined with other trends previously in play, suggest that demands to cut costs and do more with less will be relentless as the field – and the world – tries to pull out of the pandemic crisis.
Compensation trends
One of the most eagerly anticipated findings in the SoHM is compensation. The median compensation for all adult hospitalists at the beginning of 2020 was $307,633 (with an average of $317,640), higher in the Midwest and lower in the East. The average base rate share of hospitalist compensation was 81.3%, with 11.6% based on productivity and 7.1% for performance – scored on such measures as patient satisfaction; accuracy and/or timeliness of documentation, billing, and coding; clinical processes; early morning discharge orders and times; and readmissions rates. A total of 46.6% of responding groups said they anticipated an increase in budgeted FTEs in the next year, while 51.2% expected to stay the same.
Subsidies or financial support for hospitalist practices break down in different ways, but in 2020 the median figure for financial support provided per adult hospitalist FTE was $198,750 (average, $201,760). This suggests that hospitals continue to see hospitalists as valued partners in health care, with useful knowledge of how the various components of the health care system work, said Tresa McNeal, MD, a hospitalist at Baylor Scott & White Medical Center, Temple, Tex., and a member of the PAC.
Scope of practice
Scope of practice for the hospitalist model continues to evolve, with increased demand for comanagement roles as other medical specialties are less inclined to visit patients in the hospital. Surgical comanagement accounted for much of that growth, but there were significant rates of comanagement for neurology, gastrointestinal and liver medicine, cardiology, and palliative care.
“Comanagement is a broad term without a single clear definition,” Ms. Flores said. “But when I talk about it, I refer to a broader array of hospitalists interacting with specialists.” The hospitalist‘s role could be as a consultant, or taking responsibility for admitting and attending.
Other identified roles played by hospitalists in adult-only groups included providing care for patients in the ICU (59.6% of reporting groups); primary responsibility for observation/short stay units, rapid response teams or code blue/cardiac arrest teams; cross-coverage for patients admitted without a hospitalist; and performing procedures such as vascular access, lumbar puncture, paracentesis, and thoracentesis. The hospitalist role’s in the ICU likely increased in many hospitals confronting COVID surges, Ms. Flores said.
The median number of shifts performed per year by a full-time hospitalist physician was 182.0 (average, 182.3), with 12 hours as the most common average duration for a shift in a daytime schedule. The 7-days-on/7-days-off model remained the most popular way to schedule adult hospitalists, at the same rate as in 2018. Backup coverage is another important issue for hospitalist groups, with 52.6% reporting no formal backup system. For those with a backup system, the highest proportion paid no additional compensation to the physician for being on the on-call schedule, but additional compensation was paid if called into the hospital.
Presence of nocturnists was reported by 71.9% of responding groups, slightly down from 2018, but increasing with the size of the group. “We continue to see a trend for dedicated nocturnists,” said Dr. McNeal. Hospitals see the benefits from the presence of a nocturnist, reflected in pay differentials or requiring fewer full-time shifts from nocturnists. It’s more consistent, higher quality of care delivered by people who are dedicated to that role.
In other findings from the survey, turnover in adult hospitalist groups is 10.9%t, which is up from 2018 but down from 2016. Unit-based assignment, also known as geographical rounding, was utilized by 42.7% of responding adult groups, with likelihood increasing with the size of the group. Unfilled positions were reported by 73.5% of groups, with an average of 11.2% of positions unfilled at the time of the survey.
The use of telemedicine in the hospital setting is evolving, likely considerably accelerated of necessity by the pandemic. “Many of us are using telemedicine with COVID patients in order to decrease clinicians’ time in the room, and to find a way to use a work force that has to be on leave,” Dr. McNeal said.
Nurse practitioners and physician assistants
The role for nurse practitioners and physician assistants in adult hospital medicine groups continues to increase, with 83.3% of groups reporting the presence of PAs and NPs, up from 77% in 2018. NPs/PAs are more likely in multistate hospitalist groups or integrated delivery system practices in hospitals/health systems.
The most common billing model for their professional services is a combination of independent billing by the PA/NP where allowed and shared services billing under a supervisory physician’s provider number – although 8.1% of groups report that their NPs/PAs didn’t generally provide billable services or submit bills for payment.
NPs and PAs spend one-fifth of their time, on average, on nonbillable, value-added work, including dedicated cross-coverage shifts, scheduling, patient assignments, nonbillable clinical work such as glycemic control, and quality improvement and performance improvement activities. “This is one example of the changing skill mix for the hospitalist group, helping the practice become more efficient,” Ms. Flores said.
NPs and PAs provide valuable services, Dr. McNeal added. “But it also takes some investment in time and training for them to be able to practice at the top of their license. My own hospitalist group has a training program for newly hired NPs/PAs. Everyone goes through this orientation for around 6-10 weeks, largely in a shadowing role starting out, until they gradually adjust to more clinical autonomy.”
This onboarding includes real-time evaluations and self-evaluations, and opportunities for conversations with experienced clinicians, working from a list of 30 “bread-and-butter” topics in hospital medicine, she noted.
Pediatric hospital medicine
The 2020 SoHM report includes a greater representation for pediatric hospital medicine, with a 200% increase in the proportion of reporting hospitalist groups that only take care of children. Thus, the pediatric data are more robust – and helpful – than in prior year surveys, said Sandra Gage, MD, SFHM, a pediatric hospitalist at Phoenix Children’s Hospital. Dr. Gage headed up the PAC’s expanded pediatric data initiative, with targeted outreach to pediatric groups to encourage their participation. She also convened a task force to come up with pediatric-specific questions that were more pertinent and user friendly.
One of the important questions for pediatric hospitalists involves scheduling – including variations in length of shifts – which can vary dramatically in pediatric HM groups. “This year we reported by number of hours expected for a clinical FTE, which should be more useful for group leaders,” Dr. Gage said. The median number of hours required per FTE from pediatric hospitalists was fairly consistent at 1,800 per year, with minor variations based on region and academic status.
“I don’t know that there’s anything too surprising in most of the data,” she said, but noted that SHM will now have a better pediatric baseline going forward. The survey also asked how many pediatric hospitalists were board certified in the new subspecialty of pediatric hospital medicine under the program launched last year by the American Board of Pediatrics. Its first qualifying exam was in November 2019. The average was 26%, but the variation between academic and nonacademic programs was unexpected, Dr. Gage said.
Pediatric hospitalists come from a variety of professional specialties besides pediatrics. Nearly half of all programs had at least one med/peds provider, while a smaller number of programs had providers from family medicine, internal medicine, emergency medicine, or palliative care, she noted. Half of pediatric hospitalists reported joining their practice directly out of residency. About 26% of pediatric hospital medicine (PHM) physicians were described as part time, and 34.3% of pediatric groups had the presence of an NP or PA.
“I think PHM evolved a little later than for adult hospitalists, but it has clearly come into its own as a field,” Dr. Gage said. In the COVID-19 crisis, some pediatric hospitalists have been asked to care for adult patients, which necessitated a flurry of activity to refresh their medical knowledge. Where pediatric units existed within the walls of adult hospitals and were temporarily closed for COVID, it’s not clear how many will reopen – perhaps ever.
Long-term impacts of the crisis
Some of the hospitalist group leaders Ms. Flores has spoken with in recent months point out that, while New York and some other early COVID-19 hot spots experienced a tremendous surge of patients and hospital crowding in March and April 2020, other hospitals didn’t see anywhere near the impact.
“For some, there was nothing going on with COVID where they were,” she said. Elective surgeries were widely canceled, but with no corresponding increase of COVID admissions; and with fewer patients showing up in EDs, some physicians found themselves idled.
What will be the longer-term impact of COVID-19? How will it change hospital medicine? “I definitely think things are going to change,” Ms. Flores said, speculating that licensing boards could find a way to make it easier for physicians to practice across state lines in response to crises like the pandemic. “Do we need to think at the national level about what we can do to create more surge capacity, to move people when and where they need to go in a crisis? Are there things SHM could do to help?”
Ms. Flores expects more hospital closures than followed the 2008-2009 economic recession, which likely will further drive the trend toward mergers and acquisitions – both of hospitalist groups and of hospitals.
“From the point of view of hospitals, financial pressures will only get worse, pressing us to reinvent how hospitalists work and how that could be made more efficient,” she said. “I hear hospitals saying: ‘We can’t sustain current trends.’ Meanwhile, specialists are saying they need more help from hospitalists, and frontline hospitalists are saying they’re already working too hard. What will we do about burnout?”
These competing trends were all headed toward a perfect storm even before the epidemic hit, Ms. Flores said. “The response will require some innovations we haven’t yet conceived of. Incremental change won’t get us where we need to be. But the hospitalist’s role will be more essential than ever.”
The 2020 data show that a lot of things have been fairly steady for hospitalists, said Thomas Frederickson, MD, a member of SHM’s PAC and a specialist in hospital medicine at CHI Health in Omaha, Neb. But one concern about this stability is that, while hospitalist compensation continues to go up, workload and by extension productivity remain relatively flat. “That has been a trend over the past decade, and some of us find it hard to make sense of that.”
Dr. Frederickson, too, sees a need for disruptive innovation. “I just wish I knew what that will be.” Perhaps, just as hospitalists played a large role in the quality revolution in hospitals over the past decade, maybe in the next decade they will come to play a large role in the right-sizing of hospital care in health systems, he said.
One other important finding: the number of hospitalists per group who play roles as physician leaders has also increased, with an average of 3.2 physicians per group in a formal leadership role (median of 2). But currently, 73% of the highest-ranking leaders in hospitalist groups are male, and they are disproportionally white. As reported in Medscape in 2019, 40% of working hospitalists are women and only 36% of hospitalists overall self-identified as White.1
“When you think of the demographics of actual working hospitalists, we could say the field of hospital medicine could and should do better in creating opportunities for diversity in leadership roles,” Ms. Flores said.
Reference
1. Martin KL. Hospitalist Compensation Report for 2019. Medscape. 2019 Jun 5. https://www.medscape.com/slideshow/2019-compensation-hospitalist-6011429#3.
Five reasons why medical meetings will never be the same
In the wake of the COVID-19 pandemic, the virtual medical meeting is now the norm. And while it’s admirable that key data are being disseminated (often for free), there is no escaping the fact that it is a fundamentally different and lesser experience.
Watching from home, most of us split our attention between live streams of the meeting and work and family obligations. There is far less urgency when early live presentations are recorded and can be viewed later.
In terms of discussing the data, Twitter may offer broader participation than a live meeting, yet only a small number of attendees actively engage online.
And the exhibit halls for these online meetings? With neither free coffee nor company-branded tchotchkes, I expect that they have virtual tumbleweeds blowing through and crickets chirping.
Even still, the virtual meeting experience, while inferior to the live one, is a tremendous advance. It should never be banished as a historical footnote but rather should remain an option. It’s analogous to watching the Super Bowl at home: Obviously, it’s not the same as being there, but it’s a terrific alternative. Like telemedicine, this pandemic has provided a critical proof of concept that there is a better model.
Reshaping the medical meeting
Let’s consider five reasons why medical meetings should be permanently reshaped by this pandemic.
This pandemic isn’t going away in 2020. While nearly every country has done a far better job than the United States of containing COVID-19 thus far, outbreaks remain a problem wherever crowds assemble. You’d be hard-pressed to devise a setting more conducive to mass spread than a conference of 20,000 attendees from all over the world sitting alongside each other cheek to jowl for 5 days. Worse yet is the thought of them returning home and infecting their patients, families, and friends. What medical society wants to be remembered for creating a COVID-19 superspreader event? Professional medical societies will need to offer this option as the safest alternative moving forward.
Virtual learning still conveys the most important content. Despite the many social benefits of a live meeting, its core purpose is to disseminate new research and current and emerging treatment options. Virtual meetings have proven that this format can effectively deliver the content, and not as a secondary offering but as the sole platform in real time.
Virtual learning levels the playing field. Traveling to attend conferences typically costs thousands of dollars, accounting for the registration fees, inflated hotel rates, ground transportation, and meals out for days on end. Most meetings also demand several days away from our work and families, forcing many of us to work extra in the days before we leave and upon our return. Parents and those with commitments at home also face special challenges. For international participants, the financial and time costs are even greater. A virtual meeting helps overcome these hurdles and erases barriers that have long precluded many from attending a conference.
Virtual learning is efficient and comfortable. Virtual meetings over the past 6 months have given us a glimpse of an astonishingly more efficient form. If the content seems of a lower magnitude without the fanfare of a live conference, it is in part because so much of a live meeting is spent walking a mile between session rooms, waiting in concession or taxi lines, sitting in traffic between venues, or simply waiting for a session to begin. All of that has been replaced with time that you can use productively in between video sessions viewed either live or on demand. And with a virtual meeting, you can comfortably watch the sessions. There’s no need to stand along the back wall of an overcrowded room or step over 10 people to squeeze into an open middle seat. You can be focused, rather than having an end-of-day presentation wash over you as your eyes cross because you’ve been running around for the past 12 hours.
Virtual learning and social media will only improve. While virtual meetings unquestionably have limitations, it’s important to acknowledge that the successes thus far still represent only the earliest forays into this endeavor. In-person meetings evolved to their present form over centuries. In contrast, virtual meetings are being cobbled together within a few weeks or months. They can only be expected to improve as presenters adapt their skills to the online audience and new tools improve virtual discussions.
I am not implying that live meetings will or should be replaced by virtual ones. We still need that experience of trainees and experts presenting to a live audience and discussing the results together, all while sharing the energy of the moment. But there should be room for both a live conference and a virtual version.
Practically speaking, it is unclear whether professional societies could forgo the revenue they receive from registration fees, meeting sponsorships, and corporate exhibits. Yet, there are certainly ways to obtain sponsorship revenue for a virtual program. Even if the virtual version of a conference costs far less than attending in person, there is plenty of room between that number and free. It costs remarkably little for a professional society to share its content, and virtual offerings further the mission of distributing this content broadly.
We should not rush to return to the previous status quo. Despite their limitations, virtual meetings have brought a new, higher standard of access and efficiency for sharing important new data and treatment options in medicine.
H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, Calif., regularly comments on lung cancer for Medscape. West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.
This article first appeared on Medscape.com.
In the wake of the COVID-19 pandemic, the virtual medical meeting is now the norm. And while it’s admirable that key data are being disseminated (often for free), there is no escaping the fact that it is a fundamentally different and lesser experience.
Watching from home, most of us split our attention between live streams of the meeting and work and family obligations. There is far less urgency when early live presentations are recorded and can be viewed later.
In terms of discussing the data, Twitter may offer broader participation than a live meeting, yet only a small number of attendees actively engage online.
And the exhibit halls for these online meetings? With neither free coffee nor company-branded tchotchkes, I expect that they have virtual tumbleweeds blowing through and crickets chirping.
Even still, the virtual meeting experience, while inferior to the live one, is a tremendous advance. It should never be banished as a historical footnote but rather should remain an option. It’s analogous to watching the Super Bowl at home: Obviously, it’s not the same as being there, but it’s a terrific alternative. Like telemedicine, this pandemic has provided a critical proof of concept that there is a better model.
Reshaping the medical meeting
Let’s consider five reasons why medical meetings should be permanently reshaped by this pandemic.
This pandemic isn’t going away in 2020. While nearly every country has done a far better job than the United States of containing COVID-19 thus far, outbreaks remain a problem wherever crowds assemble. You’d be hard-pressed to devise a setting more conducive to mass spread than a conference of 20,000 attendees from all over the world sitting alongside each other cheek to jowl for 5 days. Worse yet is the thought of them returning home and infecting their patients, families, and friends. What medical society wants to be remembered for creating a COVID-19 superspreader event? Professional medical societies will need to offer this option as the safest alternative moving forward.
Virtual learning still conveys the most important content. Despite the many social benefits of a live meeting, its core purpose is to disseminate new research and current and emerging treatment options. Virtual meetings have proven that this format can effectively deliver the content, and not as a secondary offering but as the sole platform in real time.
Virtual learning levels the playing field. Traveling to attend conferences typically costs thousands of dollars, accounting for the registration fees, inflated hotel rates, ground transportation, and meals out for days on end. Most meetings also demand several days away from our work and families, forcing many of us to work extra in the days before we leave and upon our return. Parents and those with commitments at home also face special challenges. For international participants, the financial and time costs are even greater. A virtual meeting helps overcome these hurdles and erases barriers that have long precluded many from attending a conference.
Virtual learning is efficient and comfortable. Virtual meetings over the past 6 months have given us a glimpse of an astonishingly more efficient form. If the content seems of a lower magnitude without the fanfare of a live conference, it is in part because so much of a live meeting is spent walking a mile between session rooms, waiting in concession or taxi lines, sitting in traffic between venues, or simply waiting for a session to begin. All of that has been replaced with time that you can use productively in between video sessions viewed either live or on demand. And with a virtual meeting, you can comfortably watch the sessions. There’s no need to stand along the back wall of an overcrowded room or step over 10 people to squeeze into an open middle seat. You can be focused, rather than having an end-of-day presentation wash over you as your eyes cross because you’ve been running around for the past 12 hours.
Virtual learning and social media will only improve. While virtual meetings unquestionably have limitations, it’s important to acknowledge that the successes thus far still represent only the earliest forays into this endeavor. In-person meetings evolved to their present form over centuries. In contrast, virtual meetings are being cobbled together within a few weeks or months. They can only be expected to improve as presenters adapt their skills to the online audience and new tools improve virtual discussions.
I am not implying that live meetings will or should be replaced by virtual ones. We still need that experience of trainees and experts presenting to a live audience and discussing the results together, all while sharing the energy of the moment. But there should be room for both a live conference and a virtual version.
Practically speaking, it is unclear whether professional societies could forgo the revenue they receive from registration fees, meeting sponsorships, and corporate exhibits. Yet, there are certainly ways to obtain sponsorship revenue for a virtual program. Even if the virtual version of a conference costs far less than attending in person, there is plenty of room between that number and free. It costs remarkably little for a professional society to share its content, and virtual offerings further the mission of distributing this content broadly.
We should not rush to return to the previous status quo. Despite their limitations, virtual meetings have brought a new, higher standard of access and efficiency for sharing important new data and treatment options in medicine.
H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, Calif., regularly comments on lung cancer for Medscape. West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.
This article first appeared on Medscape.com.
In the wake of the COVID-19 pandemic, the virtual medical meeting is now the norm. And while it’s admirable that key data are being disseminated (often for free), there is no escaping the fact that it is a fundamentally different and lesser experience.
Watching from home, most of us split our attention between live streams of the meeting and work and family obligations. There is far less urgency when early live presentations are recorded and can be viewed later.
In terms of discussing the data, Twitter may offer broader participation than a live meeting, yet only a small number of attendees actively engage online.
And the exhibit halls for these online meetings? With neither free coffee nor company-branded tchotchkes, I expect that they have virtual tumbleweeds blowing through and crickets chirping.
Even still, the virtual meeting experience, while inferior to the live one, is a tremendous advance. It should never be banished as a historical footnote but rather should remain an option. It’s analogous to watching the Super Bowl at home: Obviously, it’s not the same as being there, but it’s a terrific alternative. Like telemedicine, this pandemic has provided a critical proof of concept that there is a better model.
Reshaping the medical meeting
Let’s consider five reasons why medical meetings should be permanently reshaped by this pandemic.
This pandemic isn’t going away in 2020. While nearly every country has done a far better job than the United States of containing COVID-19 thus far, outbreaks remain a problem wherever crowds assemble. You’d be hard-pressed to devise a setting more conducive to mass spread than a conference of 20,000 attendees from all over the world sitting alongside each other cheek to jowl for 5 days. Worse yet is the thought of them returning home and infecting their patients, families, and friends. What medical society wants to be remembered for creating a COVID-19 superspreader event? Professional medical societies will need to offer this option as the safest alternative moving forward.
Virtual learning still conveys the most important content. Despite the many social benefits of a live meeting, its core purpose is to disseminate new research and current and emerging treatment options. Virtual meetings have proven that this format can effectively deliver the content, and not as a secondary offering but as the sole platform in real time.
Virtual learning levels the playing field. Traveling to attend conferences typically costs thousands of dollars, accounting for the registration fees, inflated hotel rates, ground transportation, and meals out for days on end. Most meetings also demand several days away from our work and families, forcing many of us to work extra in the days before we leave and upon our return. Parents and those with commitments at home also face special challenges. For international participants, the financial and time costs are even greater. A virtual meeting helps overcome these hurdles and erases barriers that have long precluded many from attending a conference.
Virtual learning is efficient and comfortable. Virtual meetings over the past 6 months have given us a glimpse of an astonishingly more efficient form. If the content seems of a lower magnitude without the fanfare of a live conference, it is in part because so much of a live meeting is spent walking a mile between session rooms, waiting in concession or taxi lines, sitting in traffic between venues, or simply waiting for a session to begin. All of that has been replaced with time that you can use productively in between video sessions viewed either live or on demand. And with a virtual meeting, you can comfortably watch the sessions. There’s no need to stand along the back wall of an overcrowded room or step over 10 people to squeeze into an open middle seat. You can be focused, rather than having an end-of-day presentation wash over you as your eyes cross because you’ve been running around for the past 12 hours.
Virtual learning and social media will only improve. While virtual meetings unquestionably have limitations, it’s important to acknowledge that the successes thus far still represent only the earliest forays into this endeavor. In-person meetings evolved to their present form over centuries. In contrast, virtual meetings are being cobbled together within a few weeks or months. They can only be expected to improve as presenters adapt their skills to the online audience and new tools improve virtual discussions.
I am not implying that live meetings will or should be replaced by virtual ones. We still need that experience of trainees and experts presenting to a live audience and discussing the results together, all while sharing the energy of the moment. But there should be room for both a live conference and a virtual version.
Practically speaking, it is unclear whether professional societies could forgo the revenue they receive from registration fees, meeting sponsorships, and corporate exhibits. Yet, there are certainly ways to obtain sponsorship revenue for a virtual program. Even if the virtual version of a conference costs far less than attending in person, there is plenty of room between that number and free. It costs remarkably little for a professional society to share its content, and virtual offerings further the mission of distributing this content broadly.
We should not rush to return to the previous status quo. Despite their limitations, virtual meetings have brought a new, higher standard of access and efficiency for sharing important new data and treatment options in medicine.
H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, Calif., regularly comments on lung cancer for Medscape. West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.
This article first appeared on Medscape.com.
HM20 Virtual: Improved supervision of residents
HM20 Virtual session title
Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision
Presenter
Daniel Steinberg, MD, SFHM, FACP
Session summary
In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.
Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?
The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
Key takeaways
- Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
- Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
- To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.
Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.
HM20 Virtual session title
Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision
Presenter
Daniel Steinberg, MD, SFHM, FACP
Session summary
In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.
Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?
The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
Key takeaways
- Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
- Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
- To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.
Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.
HM20 Virtual session title
Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision
Presenter
Daniel Steinberg, MD, SFHM, FACP
Session summary
In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.
Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?
The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
Key takeaways
- Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
- Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
- To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.
Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.
HHS plan to improve rural health focuses on better broadband, telehealth services
Even before the coronavirus pandemic reached into the nation’s less-populated regions, rural Americans were sicker, poorer, and older than the rest of the country. Hospitals are shuttering at record rates, and health care experts have long called for changes.
The new plan, released by the Department of Health & Human Services Secretary Alex M. Azar, II, acknowledges the gaps in health care and other problems facing rural America. It lists a litany of projects and directives, with many already underway or announced within federal agencies.
“We cannot just tinker around the edges of a rural healthcare system that has struggled for too long,” Azar said in a prepared statement.
Yet, that is exactly what experts say the administration continues to do.
“They tinker around the edges,” said Tommy Barnhart, former president of the National Rural Health Association. And he added, “there’s a lot of political hype” that has happened under President Trump, as well as previous presidents.
In the past few months, rural health care has increasingly become a focus for Mr. Trump, whose polling numbers are souring as COVID-19 kills hundreds of Americans every day, drives down restaurant demand for some farm products, and spreads through meatpacking plants. Rural states including Iowa and the Dakotas are reporting the latest surges in cases.
This announcement comes in response to Mr. Trump’s executive order last month calling for improved rural health and telehealth access. Earlier this week, three federal agencies also announced they would team up to address gaps in rural broadband service – a key need because large portions of the plan seek to expand telehealth.
The plan is more than 70 pages long and the word “telehealth” appears more than 90 times, with a focus on projects across HHS, including the Health Resources and Services Administration and the Centers for Medicare & Medicaid Services.
Mr. Barnhart said CMS has passed some public health emergency waivers since the beginning of the pandemic that helped rural facilities get more funding, including one that specifically was designed to provide additional money for telehealth services. However, those waivers are set to expire when the coronavirus emergency ends. Officials have not yet set a date for when the federal emergency will end.
Andrew Jay Schwartzman, senior counselor to the Benton Institute for Broadband & Society, a private foundation that works to ensure greater Internet access, said there are multiple challenges with implementing telehealth across the nation. Many initiatives for robust telehealth programs need fast bandwidth, yet getting the money and setting up the necessary infrastructure is very difficult, he said.
“It will be a long time before this kind of technology will be readily available to much of the country,” he said.
Ge Bai, associate professor of accounting and health policy at Johns Hopkins University in Baltimore, noted that telehealth was short on funding in the HHS initiative. However, she said, the focus on telehealth, as well as a proposed shift in payment for small rural hospitals and changing workforce licensing requirements, had good potential.
“We are so close to the election that this is probably more of a messaging issue to cater to rural residents,” Ms. Bai said. “But it doesn’t matter who will be president. This report will give the next administration useful guidance.”
The American Hospital Association, representing 5,000 hospitals nationwide, sent a letter to Mr. Trump last week recommending a host of steps the administration could take. As of late Thursday, AHA was still reviewing the HHS plan but said it was “encouraged by the increased attention on rural health care.”
Buried within the HHS announcement are technical initiatives, such as a contract to help clinics and hospitals integrate care, and detailed efforts to address gaps in care, including a proposal to increase funding for school-based mental health programs in the president’s 2021 budget.
A senior HHS official said that, while some actions have been taken in recent months to improve rural health — such as the $11 billion provided to rural hospitals through coronavirus relief funding — more is needed.
“We’re putting our stake in the ground that the time for talk is over,” he said. “We’re going to move forward.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Even before the coronavirus pandemic reached into the nation’s less-populated regions, rural Americans were sicker, poorer, and older than the rest of the country. Hospitals are shuttering at record rates, and health care experts have long called for changes.
The new plan, released by the Department of Health & Human Services Secretary Alex M. Azar, II, acknowledges the gaps in health care and other problems facing rural America. It lists a litany of projects and directives, with many already underway or announced within federal agencies.
“We cannot just tinker around the edges of a rural healthcare system that has struggled for too long,” Azar said in a prepared statement.
Yet, that is exactly what experts say the administration continues to do.
“They tinker around the edges,” said Tommy Barnhart, former president of the National Rural Health Association. And he added, “there’s a lot of political hype” that has happened under President Trump, as well as previous presidents.
In the past few months, rural health care has increasingly become a focus for Mr. Trump, whose polling numbers are souring as COVID-19 kills hundreds of Americans every day, drives down restaurant demand for some farm products, and spreads through meatpacking plants. Rural states including Iowa and the Dakotas are reporting the latest surges in cases.
This announcement comes in response to Mr. Trump’s executive order last month calling for improved rural health and telehealth access. Earlier this week, three federal agencies also announced they would team up to address gaps in rural broadband service – a key need because large portions of the plan seek to expand telehealth.
The plan is more than 70 pages long and the word “telehealth” appears more than 90 times, with a focus on projects across HHS, including the Health Resources and Services Administration and the Centers for Medicare & Medicaid Services.
Mr. Barnhart said CMS has passed some public health emergency waivers since the beginning of the pandemic that helped rural facilities get more funding, including one that specifically was designed to provide additional money for telehealth services. However, those waivers are set to expire when the coronavirus emergency ends. Officials have not yet set a date for when the federal emergency will end.
Andrew Jay Schwartzman, senior counselor to the Benton Institute for Broadband & Society, a private foundation that works to ensure greater Internet access, said there are multiple challenges with implementing telehealth across the nation. Many initiatives for robust telehealth programs need fast bandwidth, yet getting the money and setting up the necessary infrastructure is very difficult, he said.
“It will be a long time before this kind of technology will be readily available to much of the country,” he said.
Ge Bai, associate professor of accounting and health policy at Johns Hopkins University in Baltimore, noted that telehealth was short on funding in the HHS initiative. However, she said, the focus on telehealth, as well as a proposed shift in payment for small rural hospitals and changing workforce licensing requirements, had good potential.
“We are so close to the election that this is probably more of a messaging issue to cater to rural residents,” Ms. Bai said. “But it doesn’t matter who will be president. This report will give the next administration useful guidance.”
The American Hospital Association, representing 5,000 hospitals nationwide, sent a letter to Mr. Trump last week recommending a host of steps the administration could take. As of late Thursday, AHA was still reviewing the HHS plan but said it was “encouraged by the increased attention on rural health care.”
Buried within the HHS announcement are technical initiatives, such as a contract to help clinics and hospitals integrate care, and detailed efforts to address gaps in care, including a proposal to increase funding for school-based mental health programs in the president’s 2021 budget.
A senior HHS official said that, while some actions have been taken in recent months to improve rural health — such as the $11 billion provided to rural hospitals through coronavirus relief funding — more is needed.
“We’re putting our stake in the ground that the time for talk is over,” he said. “We’re going to move forward.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Even before the coronavirus pandemic reached into the nation’s less-populated regions, rural Americans were sicker, poorer, and older than the rest of the country. Hospitals are shuttering at record rates, and health care experts have long called for changes.
The new plan, released by the Department of Health & Human Services Secretary Alex M. Azar, II, acknowledges the gaps in health care and other problems facing rural America. It lists a litany of projects and directives, with many already underway or announced within federal agencies.
“We cannot just tinker around the edges of a rural healthcare system that has struggled for too long,” Azar said in a prepared statement.
Yet, that is exactly what experts say the administration continues to do.
“They tinker around the edges,” said Tommy Barnhart, former president of the National Rural Health Association. And he added, “there’s a lot of political hype” that has happened under President Trump, as well as previous presidents.
In the past few months, rural health care has increasingly become a focus for Mr. Trump, whose polling numbers are souring as COVID-19 kills hundreds of Americans every day, drives down restaurant demand for some farm products, and spreads through meatpacking plants. Rural states including Iowa and the Dakotas are reporting the latest surges in cases.
This announcement comes in response to Mr. Trump’s executive order last month calling for improved rural health and telehealth access. Earlier this week, three federal agencies also announced they would team up to address gaps in rural broadband service – a key need because large portions of the plan seek to expand telehealth.
The plan is more than 70 pages long and the word “telehealth” appears more than 90 times, with a focus on projects across HHS, including the Health Resources and Services Administration and the Centers for Medicare & Medicaid Services.
Mr. Barnhart said CMS has passed some public health emergency waivers since the beginning of the pandemic that helped rural facilities get more funding, including one that specifically was designed to provide additional money for telehealth services. However, those waivers are set to expire when the coronavirus emergency ends. Officials have not yet set a date for when the federal emergency will end.
Andrew Jay Schwartzman, senior counselor to the Benton Institute for Broadband & Society, a private foundation that works to ensure greater Internet access, said there are multiple challenges with implementing telehealth across the nation. Many initiatives for robust telehealth programs need fast bandwidth, yet getting the money and setting up the necessary infrastructure is very difficult, he said.
“It will be a long time before this kind of technology will be readily available to much of the country,” he said.
Ge Bai, associate professor of accounting and health policy at Johns Hopkins University in Baltimore, noted that telehealth was short on funding in the HHS initiative. However, she said, the focus on telehealth, as well as a proposed shift in payment for small rural hospitals and changing workforce licensing requirements, had good potential.
“We are so close to the election that this is probably more of a messaging issue to cater to rural residents,” Ms. Bai said. “But it doesn’t matter who will be president. This report will give the next administration useful guidance.”
The American Hospital Association, representing 5,000 hospitals nationwide, sent a letter to Mr. Trump last week recommending a host of steps the administration could take. As of late Thursday, AHA was still reviewing the HHS plan but said it was “encouraged by the increased attention on rural health care.”
Buried within the HHS announcement are technical initiatives, such as a contract to help clinics and hospitals integrate care, and detailed efforts to address gaps in care, including a proposal to increase funding for school-based mental health programs in the president’s 2021 budget.
A senior HHS official said that, while some actions have been taken in recent months to improve rural health — such as the $11 billion provided to rural hospitals through coronavirus relief funding — more is needed.
“We’re putting our stake in the ground that the time for talk is over,” he said. “We’re going to move forward.”
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
REALITY trial supports restrictive transfusion in anemic MI
in the landmark REALITY trial.
Randomized trial data already support a restrictive transfusion strategy in patients undergoing cardiac and noncardiac surgery, as well as in other settings. Those trials deliberately excluded patients with acute myocardial ischemia.
Cardiologists have been loath to adopt a restrictive strategy in the absence of persuasive supporting evidence because of a theoretic concern that low hemoglobin might be particularly harmful to ischemic myocardium. Anemia occurs in 5%-10% patients with MI, and clinicians have been eager for evidence-based guidance on how to best manage it.
“Blood is a precious resource and transfusion is costly, logistically cumbersome, and has side effects,” Philippe Gabriel Steg, MD, chair of the REALITY trial, noted in presenting the study results at the virtual annual congress of the European Society of Cardiology.
REALITY was the first-ever large randomized trial of a restrictive versus liberal transfusion strategy in acute MI. The study, which featured a noninferiority design, included 668 stable patients with acute MI and anemia with a hemoglobin of 7-10 g/dL at 35 hospitals in France and Spain. Participants were randomized to a restrictive strategy in which transfusion was withheld unless the hemoglobin dropped to 8 g/dL or less, or to a conventional liberal strategy triggered by a hemoglobin of 10 g/dL or lower. The transfusion target was a hemoglobin level of 8-10 g/dL in the restrictive strategy group and greater than 11 g/dL in the liberal transfusion group. In the restrictive transfusion group, 36% received at least one RBC transfusion, as did 87% in the liberal transfusion study arm. The restrictive strategy group used 414 fewer units of blood.
The two coprimary endpoints were 30-day major adverse cardiovascular events and cost-effectiveness. The 30-day composite of all-cause mortality, reinfarction, stroke, and emergency percutaneous coronary intervention for myocardial ischemia occurred in 11% of the restrictive transfusion group and 14% of the liberal transfusion group. The resultant 21% relative risk reduction established that the restrictive strategy was noninferior. Of note, all of the individual components of the composite endpoint numerically favored the restrictive approach.
In terms of safety, patients in the restrictive transfusion group were significantly less likely to develop an infection, by a margin of 0% versus 1.5%. The rate of acute lung injury was also significantly lower in the restrictive group: 0.3%, compared with 2.2%. The median hospital length of stay was identical at 7 days in both groups.
The cost-effectiveness analysis concluded that the restrictive transfusion strategy had an 84% probability of being both less expensive and more effective.
Patients were enrolled in REALITY regardless of whether they had active bleeding, as long as the bleeding wasn’t deemed massive and life-threatening. Notably, there was no difference in the results of restrictive versus liberal transfusion regardless of whether active bleeding was present, nor did baseline hemoglobin or the presence or absence of preexisting anemia affect the results.
Dr. Steg noted that a much larger randomized trial of restrictive versus liberal transfusion in the setting of acute MI with anemia is underway in the United States and Canada. The 3,000-patient MINT trial, sponsored by the National Institutes of Health, is testing the superiority of restrictive transfusion, rather than its noninferiority, as in REALITY. Results are a couple of years away.
“I think that will be an important piece of additional evidence,” he said.
Discussant Marco Roffi, MD, didn’t mince words.
“I really love the REALITY trial,” declared Dr. Roffi, professor and vice chairman of the cardiology department and director of the interventional cardiology unit at University Hospital of Geneva.
He ticked off a series of reasons: The trial addressed a common clinical dilemma about which there has been essentially no prior high-quality evidence, it provided convincing results, and it carried important implications for responsible stewardship of the blood supply.
“REALITY allows clinicians to comfortably refrain from transfusing anemic patients presenting with myocardial infarction, and this should lead to a reduction in the consumption of blood products,” Dr. Roffi said.
He applauded the investigators for their success in obtaining public funding for a study lacking a commercial hook. And as a clinical investigator, he was particularly impressed by one of the technical details about the REALITY trial: “I was amazed by the fact that the observed event rates virtually corresponded to the estimated ones used for the power calculations. This is rarely the case in such a trial.”
Dr. Roffi said the REALITY findings should have an immediate impact on clinical practice, as well as on the brand new 2020 ESC guidelines on the management of non–ST-elevation ACS issued during the ESC virtual congress.
The freshly inked guidelines state: “Based on inconsistent study results and the lack of adequately powered randomized, controlled trials, a restrictive policy of transfusion in anemic patients with MI may be considered.” As of today, Dr. Roffi argued, the phrase “may be considered” ought to be replaced by the stronger phrase “should be considered.”
During the discussion period, he was asked if it’s appropriate to extrapolate the REALITY results to patients undergoing transcatheter aortic valve replacement, among whom anemia is highly prevalent.
“I think this is a different patient population. Nevertheless, the concept of being restrictive is one that in my opinion now remains until proven otherwise. So we are being very restrictive in these patients,” he replied.
Asked about possible mechanisms by which liberal transfusion might have detrimental effects in acute MI patients, Dr. Steg cited several, including evidence that transfusion may not improve oxygen delivery to as great an extent as traditionally thought. There is also the risk of volume overload, increased blood viscosity, and enhanced platelet aggregation and activation, which could promote myocardial ischemia.
The REALITY trial was funded by the French Ministry of Health and the Spanish Ministry of Economy and Competitiveness with no commercial support. Outside the scope of the trial, Dr. Steg reported receiving research grants from Bayer, Merck, Servier, and Sanofi as well as serving as a consultant to numerous pharmaceutical companies.
in the landmark REALITY trial.
Randomized trial data already support a restrictive transfusion strategy in patients undergoing cardiac and noncardiac surgery, as well as in other settings. Those trials deliberately excluded patients with acute myocardial ischemia.
Cardiologists have been loath to adopt a restrictive strategy in the absence of persuasive supporting evidence because of a theoretic concern that low hemoglobin might be particularly harmful to ischemic myocardium. Anemia occurs in 5%-10% patients with MI, and clinicians have been eager for evidence-based guidance on how to best manage it.
“Blood is a precious resource and transfusion is costly, logistically cumbersome, and has side effects,” Philippe Gabriel Steg, MD, chair of the REALITY trial, noted in presenting the study results at the virtual annual congress of the European Society of Cardiology.
REALITY was the first-ever large randomized trial of a restrictive versus liberal transfusion strategy in acute MI. The study, which featured a noninferiority design, included 668 stable patients with acute MI and anemia with a hemoglobin of 7-10 g/dL at 35 hospitals in France and Spain. Participants were randomized to a restrictive strategy in which transfusion was withheld unless the hemoglobin dropped to 8 g/dL or less, or to a conventional liberal strategy triggered by a hemoglobin of 10 g/dL or lower. The transfusion target was a hemoglobin level of 8-10 g/dL in the restrictive strategy group and greater than 11 g/dL in the liberal transfusion group. In the restrictive transfusion group, 36% received at least one RBC transfusion, as did 87% in the liberal transfusion study arm. The restrictive strategy group used 414 fewer units of blood.
The two coprimary endpoints were 30-day major adverse cardiovascular events and cost-effectiveness. The 30-day composite of all-cause mortality, reinfarction, stroke, and emergency percutaneous coronary intervention for myocardial ischemia occurred in 11% of the restrictive transfusion group and 14% of the liberal transfusion group. The resultant 21% relative risk reduction established that the restrictive strategy was noninferior. Of note, all of the individual components of the composite endpoint numerically favored the restrictive approach.
In terms of safety, patients in the restrictive transfusion group were significantly less likely to develop an infection, by a margin of 0% versus 1.5%. The rate of acute lung injury was also significantly lower in the restrictive group: 0.3%, compared with 2.2%. The median hospital length of stay was identical at 7 days in both groups.
The cost-effectiveness analysis concluded that the restrictive transfusion strategy had an 84% probability of being both less expensive and more effective.
Patients were enrolled in REALITY regardless of whether they had active bleeding, as long as the bleeding wasn’t deemed massive and life-threatening. Notably, there was no difference in the results of restrictive versus liberal transfusion regardless of whether active bleeding was present, nor did baseline hemoglobin or the presence or absence of preexisting anemia affect the results.
Dr. Steg noted that a much larger randomized trial of restrictive versus liberal transfusion in the setting of acute MI with anemia is underway in the United States and Canada. The 3,000-patient MINT trial, sponsored by the National Institutes of Health, is testing the superiority of restrictive transfusion, rather than its noninferiority, as in REALITY. Results are a couple of years away.
“I think that will be an important piece of additional evidence,” he said.
Discussant Marco Roffi, MD, didn’t mince words.
“I really love the REALITY trial,” declared Dr. Roffi, professor and vice chairman of the cardiology department and director of the interventional cardiology unit at University Hospital of Geneva.
He ticked off a series of reasons: The trial addressed a common clinical dilemma about which there has been essentially no prior high-quality evidence, it provided convincing results, and it carried important implications for responsible stewardship of the blood supply.
“REALITY allows clinicians to comfortably refrain from transfusing anemic patients presenting with myocardial infarction, and this should lead to a reduction in the consumption of blood products,” Dr. Roffi said.
He applauded the investigators for their success in obtaining public funding for a study lacking a commercial hook. And as a clinical investigator, he was particularly impressed by one of the technical details about the REALITY trial: “I was amazed by the fact that the observed event rates virtually corresponded to the estimated ones used for the power calculations. This is rarely the case in such a trial.”
Dr. Roffi said the REALITY findings should have an immediate impact on clinical practice, as well as on the brand new 2020 ESC guidelines on the management of non–ST-elevation ACS issued during the ESC virtual congress.
The freshly inked guidelines state: “Based on inconsistent study results and the lack of adequately powered randomized, controlled trials, a restrictive policy of transfusion in anemic patients with MI may be considered.” As of today, Dr. Roffi argued, the phrase “may be considered” ought to be replaced by the stronger phrase “should be considered.”
During the discussion period, he was asked if it’s appropriate to extrapolate the REALITY results to patients undergoing transcatheter aortic valve replacement, among whom anemia is highly prevalent.
“I think this is a different patient population. Nevertheless, the concept of being restrictive is one that in my opinion now remains until proven otherwise. So we are being very restrictive in these patients,” he replied.
Asked about possible mechanisms by which liberal transfusion might have detrimental effects in acute MI patients, Dr. Steg cited several, including evidence that transfusion may not improve oxygen delivery to as great an extent as traditionally thought. There is also the risk of volume overload, increased blood viscosity, and enhanced platelet aggregation and activation, which could promote myocardial ischemia.
The REALITY trial was funded by the French Ministry of Health and the Spanish Ministry of Economy and Competitiveness with no commercial support. Outside the scope of the trial, Dr. Steg reported receiving research grants from Bayer, Merck, Servier, and Sanofi as well as serving as a consultant to numerous pharmaceutical companies.
in the landmark REALITY trial.
Randomized trial data already support a restrictive transfusion strategy in patients undergoing cardiac and noncardiac surgery, as well as in other settings. Those trials deliberately excluded patients with acute myocardial ischemia.
Cardiologists have been loath to adopt a restrictive strategy in the absence of persuasive supporting evidence because of a theoretic concern that low hemoglobin might be particularly harmful to ischemic myocardium. Anemia occurs in 5%-10% patients with MI, and clinicians have been eager for evidence-based guidance on how to best manage it.
“Blood is a precious resource and transfusion is costly, logistically cumbersome, and has side effects,” Philippe Gabriel Steg, MD, chair of the REALITY trial, noted in presenting the study results at the virtual annual congress of the European Society of Cardiology.
REALITY was the first-ever large randomized trial of a restrictive versus liberal transfusion strategy in acute MI. The study, which featured a noninferiority design, included 668 stable patients with acute MI and anemia with a hemoglobin of 7-10 g/dL at 35 hospitals in France and Spain. Participants were randomized to a restrictive strategy in which transfusion was withheld unless the hemoglobin dropped to 8 g/dL or less, or to a conventional liberal strategy triggered by a hemoglobin of 10 g/dL or lower. The transfusion target was a hemoglobin level of 8-10 g/dL in the restrictive strategy group and greater than 11 g/dL in the liberal transfusion group. In the restrictive transfusion group, 36% received at least one RBC transfusion, as did 87% in the liberal transfusion study arm. The restrictive strategy group used 414 fewer units of blood.
The two coprimary endpoints were 30-day major adverse cardiovascular events and cost-effectiveness. The 30-day composite of all-cause mortality, reinfarction, stroke, and emergency percutaneous coronary intervention for myocardial ischemia occurred in 11% of the restrictive transfusion group and 14% of the liberal transfusion group. The resultant 21% relative risk reduction established that the restrictive strategy was noninferior. Of note, all of the individual components of the composite endpoint numerically favored the restrictive approach.
In terms of safety, patients in the restrictive transfusion group were significantly less likely to develop an infection, by a margin of 0% versus 1.5%. The rate of acute lung injury was also significantly lower in the restrictive group: 0.3%, compared with 2.2%. The median hospital length of stay was identical at 7 days in both groups.
The cost-effectiveness analysis concluded that the restrictive transfusion strategy had an 84% probability of being both less expensive and more effective.
Patients were enrolled in REALITY regardless of whether they had active bleeding, as long as the bleeding wasn’t deemed massive and life-threatening. Notably, there was no difference in the results of restrictive versus liberal transfusion regardless of whether active bleeding was present, nor did baseline hemoglobin or the presence or absence of preexisting anemia affect the results.
Dr. Steg noted that a much larger randomized trial of restrictive versus liberal transfusion in the setting of acute MI with anemia is underway in the United States and Canada. The 3,000-patient MINT trial, sponsored by the National Institutes of Health, is testing the superiority of restrictive transfusion, rather than its noninferiority, as in REALITY. Results are a couple of years away.
“I think that will be an important piece of additional evidence,” he said.
Discussant Marco Roffi, MD, didn’t mince words.
“I really love the REALITY trial,” declared Dr. Roffi, professor and vice chairman of the cardiology department and director of the interventional cardiology unit at University Hospital of Geneva.
He ticked off a series of reasons: The trial addressed a common clinical dilemma about which there has been essentially no prior high-quality evidence, it provided convincing results, and it carried important implications for responsible stewardship of the blood supply.
“REALITY allows clinicians to comfortably refrain from transfusing anemic patients presenting with myocardial infarction, and this should lead to a reduction in the consumption of blood products,” Dr. Roffi said.
He applauded the investigators for their success in obtaining public funding for a study lacking a commercial hook. And as a clinical investigator, he was particularly impressed by one of the technical details about the REALITY trial: “I was amazed by the fact that the observed event rates virtually corresponded to the estimated ones used for the power calculations. This is rarely the case in such a trial.”
Dr. Roffi said the REALITY findings should have an immediate impact on clinical practice, as well as on the brand new 2020 ESC guidelines on the management of non–ST-elevation ACS issued during the ESC virtual congress.
The freshly inked guidelines state: “Based on inconsistent study results and the lack of adequately powered randomized, controlled trials, a restrictive policy of transfusion in anemic patients with MI may be considered.” As of today, Dr. Roffi argued, the phrase “may be considered” ought to be replaced by the stronger phrase “should be considered.”
During the discussion period, he was asked if it’s appropriate to extrapolate the REALITY results to patients undergoing transcatheter aortic valve replacement, among whom anemia is highly prevalent.
“I think this is a different patient population. Nevertheless, the concept of being restrictive is one that in my opinion now remains until proven otherwise. So we are being very restrictive in these patients,” he replied.
Asked about possible mechanisms by which liberal transfusion might have detrimental effects in acute MI patients, Dr. Steg cited several, including evidence that transfusion may not improve oxygen delivery to as great an extent as traditionally thought. There is also the risk of volume overload, increased blood viscosity, and enhanced platelet aggregation and activation, which could promote myocardial ischemia.
The REALITY trial was funded by the French Ministry of Health and the Spanish Ministry of Economy and Competitiveness with no commercial support. Outside the scope of the trial, Dr. Steg reported receiving research grants from Bayer, Merck, Servier, and Sanofi as well as serving as a consultant to numerous pharmaceutical companies.
REPORTING FROM ESC CONGRESS 2020
September marks 9 months
It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.
In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.
In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.
This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.
John I. Allen, MD, MBA, AGAF
Editor in Chief
It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.
In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.
In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.
This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.
John I. Allen, MD, MBA, AGAF
Editor in Chief
It has been a busy month. September will mark the ninth month of U.S. COVID-19 with the country now surpassing 5 million cases and more than 175,000 deaths. Daily life and our medical practices will never be the same. Many have lost friends, family, businesses, and hope. Instead of acting as a nation to pull through this together, we seem to be entering a continual state of Thoreau solitude combined with Garrett Hardin’s tragedy of the commons.
In the last 2 months GI & Hepatology News published a two-part opinion piece about the acquisition of physicians’ GI practices by private equity (PE) companies. I received a strongly worded (but justified) email criticizing the newspaper for being one sided and not declaring a conflict of interest on the part of the author. For both issues, I take sole responsibility. While it is important for us to understand how PE is affecting GI practices, the author did have a personal stake in the success of this financial model. It is important to note that details of a PE acquisition can vary greatly depending on the PE company involved and PE companies looking to acquire practices now can be counted in the hundreds. The pros and cons of PE acquisitions were argued prior to COVID-19, but since the first quarter of 2020, the model is even more confusing. We will find out over the next several years whether this ever-proliferating model of practice financing will be successful or disastrous.
In November, GI & Hepatology News will publish a special supplement called Gastroenterology Data Trends. This publication will include brief, but robust snapshots of major trends in topics ranging from NAFLD, IBD, and GI cancers to the impact of COVID-19 on GI practices. We have collected a stellar group of authors to help us.
This month, the school year begins in ways that are still being sorted out. The “Big House” will not host its usual 110,000 fans packed like sardines watching Michigan football. I hope all of our readers skipped Sturgis this year. Stay safe, stay apart, and mask up.
John I. Allen, MD, MBA, AGAF
Editor in Chief
What is your diagnosis? - September 2020
Capillaria hepatica infection
The liver parenchyma shows spindle-shaped eosinophilic eggs surrounded by eosinophilic inflammatory infiltrates and epithelioid granuloma (original magnification ×200). Figure B shows spindle-shaped eosinophilic eggs with shells, radial striations, and visible polar body, containing granular eosinophilic debris (original magnification ×1000), consistent with Capillaria hepatica. Figure C reveals crescent-shaped, degenerated adult worms of C. hepatica showing longitudinal bacillary bands, vacuolated intestine, and convoluted gonads surrounded by intense eosinophilic inflammation in liver parenchyma (original magnification ×400). The outer cuticle is not appreciated because the worms are degenerated.
A review of history revealed that the child played with stray cats and had pica. He was given 10 mg/kg of oral albendazole for 16 weeks and 1 mg/kg of oral prednisolone for the first 2 weeks to prevent paradoxical inflammatory response. Thereafter, prednisolone was tapered and stopped. Pyrexia, liver size, AEC, and liver enzymes normalized at 24 hours, 72 hours, 4 months, and 5 months, respectively. At 12 months of follow-up, the child is asymptomatic.
Capillaria hepatica is a rare nematodal invasive parasitosis where humans are the dead-end host; the main lifecycle occurs between rodents and their predators. Adult worms live, mate, and lay noninfective unembryonated eggs in rodent livers. Embryogenesis occurs only after contact with the soil in two settings: 1) the rodent is eaten by the predator and the unembryonated eggs are released in the predator's feces or 2) carcass disintegration after natural death of the rodent. Humans incidentally ingest the infective embryonated eggs by soil to mouth transmission. They hatch in the human intestine and the larvae migrate through the portal vein into the liver where they mature into adult worms. In the liver, the cycle continues with the adult worms mating and laying eggs. This elicits intense inflammation with systemic symptoms.1 In the index case, we hypothesize that the toddler with pica would have come in contact with soil in the vicinity of the stray cats. This soil would have initially contained the feline feces with unembryonated eggs that later underwent embryogenesis. The triad of fever, hepatomegaly, and eosinophilia is the hallmark and characteristic liver histology clinches the diagnosis. Duration of anthelminthic therapy should be guided by AEC response.2,3
References
1. Wright K.A. Observation on the life cycle of Capillaria hepatica with a description of the adult. Can J Zool. 1961;39:167-82.
2. Berger T. Degrémont A. Gebbers J.O. et al. Hepatic capillariasis in a 1-year-old child. Eur J Pediatr. 1990;149:333-633.
3. Choe G. Lee H.S. Seo J.K. et al. Hepatic capillariasis: first case report in the Republic of Korea. Am J Trop Med Hyg. 1993;48:610-25.
Capillaria hepatica infection
The liver parenchyma shows spindle-shaped eosinophilic eggs surrounded by eosinophilic inflammatory infiltrates and epithelioid granuloma (original magnification ×200). Figure B shows spindle-shaped eosinophilic eggs with shells, radial striations, and visible polar body, containing granular eosinophilic debris (original magnification ×1000), consistent with Capillaria hepatica. Figure C reveals crescent-shaped, degenerated adult worms of C. hepatica showing longitudinal bacillary bands, vacuolated intestine, and convoluted gonads surrounded by intense eosinophilic inflammation in liver parenchyma (original magnification ×400). The outer cuticle is not appreciated because the worms are degenerated.
A review of history revealed that the child played with stray cats and had pica. He was given 10 mg/kg of oral albendazole for 16 weeks and 1 mg/kg of oral prednisolone for the first 2 weeks to prevent paradoxical inflammatory response. Thereafter, prednisolone was tapered and stopped. Pyrexia, liver size, AEC, and liver enzymes normalized at 24 hours, 72 hours, 4 months, and 5 months, respectively. At 12 months of follow-up, the child is asymptomatic.
Capillaria hepatica is a rare nematodal invasive parasitosis where humans are the dead-end host; the main lifecycle occurs between rodents and their predators. Adult worms live, mate, and lay noninfective unembryonated eggs in rodent livers. Embryogenesis occurs only after contact with the soil in two settings: 1) the rodent is eaten by the predator and the unembryonated eggs are released in the predator's feces or 2) carcass disintegration after natural death of the rodent. Humans incidentally ingest the infective embryonated eggs by soil to mouth transmission. They hatch in the human intestine and the larvae migrate through the portal vein into the liver where they mature into adult worms. In the liver, the cycle continues with the adult worms mating and laying eggs. This elicits intense inflammation with systemic symptoms.1 In the index case, we hypothesize that the toddler with pica would have come in contact with soil in the vicinity of the stray cats. This soil would have initially contained the feline feces with unembryonated eggs that later underwent embryogenesis. The triad of fever, hepatomegaly, and eosinophilia is the hallmark and characteristic liver histology clinches the diagnosis. Duration of anthelminthic therapy should be guided by AEC response.2,3
References
1. Wright K.A. Observation on the life cycle of Capillaria hepatica with a description of the adult. Can J Zool. 1961;39:167-82.
2. Berger T. Degrémont A. Gebbers J.O. et al. Hepatic capillariasis in a 1-year-old child. Eur J Pediatr. 1990;149:333-633.
3. Choe G. Lee H.S. Seo J.K. et al. Hepatic capillariasis: first case report in the Republic of Korea. Am J Trop Med Hyg. 1993;48:610-25.
Capillaria hepatica infection
The liver parenchyma shows spindle-shaped eosinophilic eggs surrounded by eosinophilic inflammatory infiltrates and epithelioid granuloma (original magnification ×200). Figure B shows spindle-shaped eosinophilic eggs with shells, radial striations, and visible polar body, containing granular eosinophilic debris (original magnification ×1000), consistent with Capillaria hepatica. Figure C reveals crescent-shaped, degenerated adult worms of C. hepatica showing longitudinal bacillary bands, vacuolated intestine, and convoluted gonads surrounded by intense eosinophilic inflammation in liver parenchyma (original magnification ×400). The outer cuticle is not appreciated because the worms are degenerated.
A review of history revealed that the child played with stray cats and had pica. He was given 10 mg/kg of oral albendazole for 16 weeks and 1 mg/kg of oral prednisolone for the first 2 weeks to prevent paradoxical inflammatory response. Thereafter, prednisolone was tapered and stopped. Pyrexia, liver size, AEC, and liver enzymes normalized at 24 hours, 72 hours, 4 months, and 5 months, respectively. At 12 months of follow-up, the child is asymptomatic.
Capillaria hepatica is a rare nematodal invasive parasitosis where humans are the dead-end host; the main lifecycle occurs between rodents and their predators. Adult worms live, mate, and lay noninfective unembryonated eggs in rodent livers. Embryogenesis occurs only after contact with the soil in two settings: 1) the rodent is eaten by the predator and the unembryonated eggs are released in the predator's feces or 2) carcass disintegration after natural death of the rodent. Humans incidentally ingest the infective embryonated eggs by soil to mouth transmission. They hatch in the human intestine and the larvae migrate through the portal vein into the liver where they mature into adult worms. In the liver, the cycle continues with the adult worms mating and laying eggs. This elicits intense inflammation with systemic symptoms.1 In the index case, we hypothesize that the toddler with pica would have come in contact with soil in the vicinity of the stray cats. This soil would have initially contained the feline feces with unembryonated eggs that later underwent embryogenesis. The triad of fever, hepatomegaly, and eosinophilia is the hallmark and characteristic liver histology clinches the diagnosis. Duration of anthelminthic therapy should be guided by AEC response.2,3
References
1. Wright K.A. Observation on the life cycle of Capillaria hepatica with a description of the adult. Can J Zool. 1961;39:167-82.
2. Berger T. Degrémont A. Gebbers J.O. et al. Hepatic capillariasis in a 1-year-old child. Eur J Pediatr. 1990;149:333-633.
3. Choe G. Lee H.S. Seo J.K. et al. Hepatic capillariasis: first case report in the Republic of Korea. Am J Trop Med Hyg. 1993;48:610-25.
A 15-month-old, previously thriving boy from western urban India was brought in with high-grade pyrexia of unknown origin for the last 45 days. He had received multiple courses of antibiotics and antimalarials elsewhere without any response. Appetite and general activity were preserved. Examination revealed mild pallor, significant nontender soft hepatomegaly (liver span of 14 cm) without splenomegaly or peripheral lymphadenopathy. Investigations showed a hemoglobin of 9 g/dL, microcytic hypochromic smear, total leukocyte count of 48,900/mm3, neutrophils at 16%, lymphocytes at 23%, eosinophils at 58%, absolute eosinophil count of 28,362/mm3, platelet count of 490,000/mm3, bilirubin of 0.8 mg/dL, aspartate aminotransferase of 203 IU/L, alanine aminotransferase of 179 IU/L, total protein of 9.3 g/dL, albumin of 3.6 g/dL, alkaline phosphatase of 203 IU/L, and gamma-glutamyl transpeptidase of 107 IU/L. Ultrasound examination and computed tomography scans of abdomen showed no focal lesions or abscesses. A bone marrow biopsy revealed an increase in eosinophils and its precursors. Echocardiography, retroviral serology, and multiple blood and urine cultures were unyielding. Liver biopsy was performed for diagnosis (Figures A-C).
Hospitalists balance work, family as pandemic boosts stress
In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.
The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.
Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.
“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.
Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.
Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”
Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.
Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.
Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.
“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.
When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.
“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”
Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.
In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.
The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.
Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.
“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.
Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.
Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”
Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.
Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.
Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.
“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.
When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.
“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”
Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.
In a Q&A session at HM20 Virtual, hosted by the Society of Hospital Medicine, Heather Nye, MD, PhD, SFHM, professor of medicine at the University of California, San Francisco, and David J. Alfandre, MD, MPH, associate professor of medicine at New York University Langone, discussed strategies to help hospitalists tend to their personal wellness during the COVID-19 pandemic.
The speakers described the complicated logistics and emotional and psychological strain that has come from working during the pandemic, while balancing home responsibilities and parenting. The session was an opportunity to humanize hospitalists’ experience as they straddle work and family.
Dr. Nye said she was still “warming up to personal wellness” because there have been so many other demands over the past several months, but that taking the time to go for walks – to bring on a feeling of health even more than the physical benefits – has been helpful. Even before the pandemic, she said, she brought a guitar to the office to take a few minutes for a hobby for which she can’t seem to find uninterrupted time at home.
“Bringing a little bit of yourself into your work life goes a long way for a lot of people,” she said.
Child care and odd hours always have been a challenge for hospitalists, the presenters said, and for those in academia, any “wiggle room” in the schedule is often taken up by education, administration, and research projects.
Dr. Alfandre said etching out time for yourself must be “a priority, or it won’t happen.” Doing so, he said, “feels indulgent but it’s not. It’s central to being able to do the kind of work you do when you’re at the hospital, at the office, and when you’re back home again.”
Dr. Nye observed that, while working from home on nonclinical work, “recognizing how little I got done was a big surprise,” and she had to “grow comfortable with that” and learn to live with the uncertainty about when that was going to change.
Both physicians described the emotional toll of worrying about their children if they have to continue distance learning.
Dr. Alfandre said that a shared Google calendar for his wife and him – with appointments, work obligations, children’s doctor’s appointments, recitals – has been helpful, removing the strain of having to remind each other. He said that there are skills used at work that hospitalists can use at home – such as not getting upset with a child for crying about a spilled drink – in the same way that a physician wouldn’t get upset with a patient concerned about a test.
“We empathize with our patients, and we empathize with our kids and what their experience is,” he said. Similarly, seeing family members crowd around a smartphone video call to check in with a COVID-19 patient can be a helpful reminder to appreciate going home to family at the end of the day.
When her children get upset that she has to go in to work, Dr. Nye said, it has been helpful to explain that her many patients are suffering and scared and need her help.
“I feel like sharing that part of our job [with] our kids helps them understand that there are very, very big problems out there – that they don’t have to know too much about and be frightened about – but [that knowledge] just gives them a little perspective.”
Dr. Nye and Dr. Alfandre said they had no financial conflicts of interest.
FROM HM20 VIRTUAL