Opinion

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

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

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

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

As working mothers with babies in tow when the COVID-19 crisis struck, countless uncertainties threatened our already precarious work-life balance. We suddenly had many questions:

“If my daycare closes, what will I do for childcare?”

“How do I navigate diaper changes, feedings, and naps with my hectic remote work schedule?”

“If I’m constantly interrupted during the day, should I skip sleep to catch up on work and not let my colleagues down?”

As professionals who work closely with medical trainees, we knew our parenting dilemmas were being experienced even more acutely by our frontline worker colleagues.

Medical training is an increasingly common time to start a family. In a recent study, 34% of trainees in Harvard-affiliated residency programs became parents during training, and another 52% planned to do so. Trainees have higher breastfeeding initiation rates but lower continuation rates than the general population. Early nursing cessation among trainees is well documented nationally and is most often attributed to work-related barriers. These barriers range from insufficient time and limited access to facilities to a lack of support and discrimination by supervisors and peers.

This trend does not discriminate by specialty. Even among training programs known to be “family friendly,” the average duration of nursing is just 4.5 months. Residents of color are disproportionately affected by inadequate support. Studies show that Black parents breastfeed at lower rates than White parents. This has been largely attributed to structural racism and implicit bias, such as Black parents receiving less assistance initiating nursing after delivery. Adequate lactation support and inclusivity are also lacking for transgender parents who choose to breastfeed or chestfeed.

The very nature of residency training, which includes shifts that can span more than 24 hours, conflicts with many health-promoting behaviors like sleeping and eating well. However, its interference with lactation is correlated with gender. Women are disproportionately affected by the negative outcomes of unmet lactation goals. These include work-life imbalance, career dissatisfaction, and negative emotions. In a study of pediatric residents, one in four did not achieve their breastfeeding goals. Respondents reported feeling “sad, devastated, defeated, disappointed, guilty, embarrassed, frustrated, angry, like a failure, and inadequate.” Among physician mothers more broadly, discrimination related to pregnancy, parental leave, and nursing is associated with higher self-reported burnout.

Navigating nursing during residency training has more than just emotional and psychological consequences – it also has professional ones. Pursuing personal lactation goals can delay residency program completion and board certification, influence specialty selection, negatively impact research productivity, impede career advancement, and lead to misgivings about career choice.

Trainees and their families are not the only ones harmed by inadequate support in residency programs. Patients and their families are affected, too. Research suggests that physicians’ personal breastfeeding practices affect the advice they give to patients. Those who receive lactation support are more likely to help patients meet their own goals. In the previously mentioned study of pediatric residents, more than 90% of the 400 respondents said their own or their partner’s nursing experience affected their interaction with lactating patients in their clinic or hospital.

Increased lactation support is a straightforward, low-cost, high-impact intervention. It benefits trainee well-being, satisfaction, workflow, and future patient care. The Accreditation Council for Graduate Medical Education mandated in July 2019 that all residency programs provide adequate lactation facilities – including refrigeration capabilities and proximity for safe patient care. However, to our knowledge, rates of compliance with this new policy and citation for noncompliance have yet to be seen. Regardless, facilities alone are not enough. Residency programs should develop and enforce formal lactation policies.

Several institutions have successfully piloted such policies in recent years. One in particular from the University of Michigan’s surgery residency program inspired the development of a lactation policy within the internal medicine residency at our institution. These policies designate appropriate spaces at each clinical rotation site, clarify that residents are encouraged to take pumping breaks as needed – in coordination with clinical teams so as not to compromise patient care – and communicate support from supervisors.

Our program also established an informal peer mentoring program. Residents with experience pumping at work pair up with newer trainees. The policy benefits residents who wish to chestfeed or breastfeed, normalizes lactation, and empowers trainees by diminishing the need to ask for individual accommodations. It also costs the program nothing.

As more women enter medicine and more trainees become parents during residency, the need for support in this area will only continue to grow. The widespread lack of such resources, and the fact that clean and private facilities are only now being mandated, is symbolic. If even this basic need is rarely acknowledged or met, what other resident needs are being neglected?

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

The vast amounts of information generated this past year related to the COVID-19 pandemic was a feat of wonder – recommendations and guidelines on the hospital level and on the national level came in a flurry, more often overwhelming and confusing than clarifying for the frontline provider. In addition, “routine” hospital care for non-infected patients and improvement processes had to continue as we all dealt with the whirlwind of increasing COVID cases, torrents of new guidelines, and educating our trainees.

Thus, the individual-level question: how does a clinician stay engaged and distill the relentless stream of new information?

In Spring 2020, when the first patients with COVID were admitted, our hospital medicine section was tasked to create a surge plan. This included organizing, orienting, and educating off-service providers on how to become hospitalists. Undoubtedly, the call to arms for our center was heard, and many responded. However, backgrounds were diverse in specialty – clinicians and trainees from psychiatry, general surgery, and various fellowships all answered. It was an exhausting and inefficient effort to produce the material, hold webinars, and schedule training, especially for those who were more removed from a hospital medicine experience. We knew we had to come up with an alternative plan moving forward.

Thus, the systems-level question: how does a health care system educate its clinicians, or any other health care providers, when reallocation of their talents and skills is both necessary, time-sensitive, and occuring during a period where new information is constantly being produced and changing?

To reach the most clinicians as possible, with the most succinct and distilled information, we had to come up with a method to do so. Ultimately, in considering the situation at hand, we had to understand who we were as the provider of the information, and who the recipient would be. We would like to share the initiatives and processes by which we constructed our solution to the two questions – microlearning through hospital podcasting.
 

Learning from our health care colleagues

With the initial webinars and training sessions for our staff, we assessed our learners’ motivations and background in managing in a hospital medicine capacity. Overall, we discovered that our trainees and clinicians have an innate drive to learn; all of them recognized the importance of keeping up with evidence-based information. However, the difficulty highlighted was the individual time available to dedicate to acquiring new information and awareness of new information being available to the health care sector during the chaotic times of the pandemic.

From our section’s perspective, we had a difficulty with coordinating among multiple professional development groups within our hospital, cost, and resources to execute training. These difficulties between providing knowledge and receiving knowledge have already been expertly analyzed.¹

Parallel to this, the pedagogic paradigm shifts as we progress through our careers – the methods and skills we used in school contrast in many ways with those we use on a daily basis when it comes to learning. Instead of dedicating hours at a time to new challenges in our workflow or our interests, we watch videos, search retailers for product solutions, check our email correspondence, and peruse social media accounts several times a day. Information comes at us very quickly, but in small pieces.

One such innovation in pedagogy is the practice of microlearning. This refers to the use of small lesson modules and short-term activities intended to teach and reinforce concepts.² It is the opposite of “macrolearning,” which is the principle of dedicating reading material, structured coursework, and traditional knowledge evaluation in the form of exams to reinforce learning. Certainly, microlearning has other names as well – “just-in-time,” “just-enough,” and “micro-courses” are a few synonyms seen in the current literature. Though a highly relevant concept for our situation, translating it to an endproduct for our trainees and clinicians required more thought.
 

From theory to application

Microlearning allows for faster delivery of information – fewer things to write means shorter course distribution times, allowing the learner to respond faster to changing educational goals and training demands. Microlearning is flexible – “micro-courses” can give a broad overview of a subject or cover complex topics broken down into simple parts. In addition, micro-learning promotes retention of key concepts – given the length of each lesson, repetition of the topic by the learner is possible at any point in time. The whole experience is similar to checking your favorite social media application on your smartphone.

Certainly, many examples of the application of microlearning are available in the health care sector – pharmaceutical and nursing training both have utilized the theory extensively.^3-4 However, in many instances, individuals were still required to sit at a workstation to complete modules and lessons. We envisioned our application of microlearning to be “on-the-go,” without necessarily requiring a computer workstation or laptop to complete.

In thinking about how social media attracts and influences clinicians, many content creators on social media come to mind. In addition, most, if not all, have branched into various social media platforms – podcasting, blogging, YouTube, for example. In thinking about our colleagues and trainees, we wanted a platform that they could take on the go, without the need to focus their visual attention (such as while driving or running). Ultimately, we believe the podcast would be the best platform to disseminate our information.

Podcasting is not foreign to medicine. A variety of medical podcasts exist, whether produced by major medical journals or by various independent health care practitioners. Both, however, have their drawbacks – the podcasts created by major medical journals are typically a summary of the publication’s content and are less engaging. Alternatively, podcasts produced by independent creators are certainly engaging and entertaining, and have a wealth of information, but the line is often blurred between just that: education and entertainment. In both instances, there is no follow-up or feedback offered to the learner in the form of surveys, or other types of feedback, which is arguably an important piece in any form of pedagogy. Thus, we sought to strike a balance between the two forms for our purposes.
 

Process of two podcasts

Our section was aware of the two aims during the pandemic – (1) disseminate new information regarding COVID-19 to the rest of our staff members and trainees as quickly as possible, and (2) maintain and improve the current quality of care of our patients. Thus, we sought to apply the reach and efficiency of the podcasting medium to provide ongoing education and feedback with respect to these two aims.

“The Cure” podcast. We recognized the constant flow of new COVID-19 information and updates and we wanted to find a readily accessible platform to reach staff with timely updates. Our marketing & communications team later helped us realize that the content we wanted to share was relevant to our patients and the community, so we formatted the material to be practical and easily digestible- something that may help an individual make decisions at the bedside as well as have conversations at the dinner table. Most recently, we engaged with our human resources department to use our platform in orienting new hires with the goal of helping staff familiarize with the institutions policies, procedures, and job aids that keep staff and patients safe.

“Antibiotry” podcast. Prior to the COVID-19 pandemic, our antibiotic stewardship group noticed an increase in antibiotic use on our medical floors. This is monitored not only through internal metrics by our pharmacy department, but also via the SAAR (standardized antibiotic administration ratio). Both sources demonstrated an increase in antibiotic use, greater than expected. An initiative was formed between our hospital medicine and infectious disease sections, and our pharmacy department to raise awareness of this increase in use, provide education to our trainees, and to create systems solutions for clinicians.

Initially, we sought to hold in-person sessions once a month for our trainees. This was led by a senior resident at the time. Topics of discussion were geared towards clinical decision making regarding empiric antibiotic use on the hospital medicine service. At the same time, our team published empiric antibiotic use guidelines, accessible through our electronic medical record. In addition, the resident leader gave a voluntary survey at the end of the session to assess not only confidence of antibiotic use, but also baseline knowledge regarding antibiotics in various clinical scenarios. This survey was repeated at the end of the resident group’s month-long rotation. Altogether, each in-person session was no longer than 10 minutes.

Unfortunately, the initiative was just gaining momentum when the COVID-19 pandemic was declared. However, we sought to take this challenge and translate it into an opportunity.

We directed our focus towards stewardship during pandemic times. Initially, our resident leader sent out email primers, approximately 3-5 minute reads, as a substitute for the in-person sessions. Our primers’ uniqueness was in its incorporation of prescription pattern data that was developed by our resident leader and our initiative’s data analyst. In doing so, we provided professional feedback regarding our antibiotic use based on the clinical indication. This was a powerful tool to not only engage our learners and staff clinicians, but also as a benchmarking tool for continued quality improvement.

But email primers are not engaging, and despite the ubiquity of teleconferencing, it was difficult to ask our housestaff to break from their morning rounds for a 10 minute tele-meeting. Thus, we devised a podcast method of education – 5-10 minute audio clips with conversation regarding a topic of discussion. This way, our trainees and learners can access episodes of education on their own time throughout the pandemic without disrupting their workflow. Given the brevity of, but high-yield content in, each episode, it would not only be convenient for listeners to access and repeat, but also for the podcaster (our resident leader) to create, as recording of the audio portion takes anywhere between 10-20 minutes for each episode, with postprocessing similarly fast.

The interdisciplinary nature of continued medical education cannot be stressed enough. With the help of our professional development team and their educators, we were able to centralize our podcast and attach surveys and additional graphics for each episode, if appropriate. This additional detail allowed for feedback, engagement with our learners, and the chance to provide additional educational points, if the learner was interested. Given the integrated nature of this platform, quality metrics could easily be recorded in the form of “click” data and various other more conventional metrics, such as listener counts and the duration of each podcast played.
 

Future applications and initiatives

Thus far, we have had great success in the reception and use of both podcasts within our institution as an application of microlearning. “The Cure” has been widely listened to by all hospital staff from various services; it has caught the attention of state-wide radio programs, and plans to expand it into the community are being discussed.

As for “Antibiotry” podcast, the concept has been lauded by our medical educators. Given its centralization within our institution, we are able to publish institution-based data as a form of professional and educational feedback to our trainees and staff physicians. This is currently coupled with the development of a provider dashboard, visualizing antibiotic prescriptions and narrowing patterns of practice within our medicine department. We plan to expand “Antibiotry” to other services at the hospital.

For both podcasts, the steps it took to achieve the final product from the microlearning concept were possible through a combination of institutional need and a motivated team. We are fortunate to have highly energetic individuals, making the coordination and planning with our hospitalists, various sub-specialists, and professional development teams straightforward. As the team grows with more individuals interested in the initiatives, keen insight into interests, individual clinical expertise, presentation skills, and technical skills ought to be carefully weighed to sustain our podcasts most efficiently, and perhaps expand them through different social media platforms.

Our objective for sustainability is through the continued outreach to and recruitment of residents and medical students, who can play key roles in the development of future projects related to these educational innovations. Both microlearning podcasts were developed through the initial planning, trial and error, and execution by two resident leaders. Their initiative and motivation to educate our institution through these platforms were highly unique; their pathfinding set the foundation for sustainability and expansion to other services.

Of course, one of the key measures we would like to investigate is whether our microlearning platform translates to improved patient outcomes. Regarding “Antibiotry,” we hope to see a decrease in unnecessary broad-spectrum antibiotic use by drawing attention to clinician practice patterns. Quality and outcome metrics will continue to be developed and measured. In addition to patient care metrics, further investigation of pedagogical metrics will be conducted, especially in the evolving realm of graduate and continuing medical education.

Measuring educational quality is neither a new ethical nor philosophical debate – neither does it carry a definitive answer. Further help from education experts may be needed to assess the quality of the information provided and its impact on our learners.
 

Conclusion

Medicine is ever-changing – the guidelines and criteria for patient care and pathology that we learned in medical school have likely changed. There is no single “best” method of learning new information in medicine, simply due to the breadth and volume of such information generated on a daily basis. This poses both a challenge for present-day clinicians and trainees, and a stimulus for change in the methods of acquiring, absorbing, and applying new information to clinical decision making and practice.

We have found that podcasting is a well-received medium of information transfer that is convenient for both the learner and the content creator. Through the podcast format, we were able to distill non-engaging pieces of education and information and transform them into short-duration lessons that the learner can listen to at their own convenience. This proved to be especially handy during the chaos of the pandemic, not only for dissemination of information regarding the management of COVID-19, but also for sustaining quality improvement goals within our institution.

Further investigation on patient outcomes and information quality are the planned next steps. In addition, expansion of other microlearning media, such as group SMS texting, YouTube videos, and Twitter, ought to be considered. Though many publications discuss the theory, potential benefits, and predicted pitfalls of microlearning, few assess the real-world application of microlearning to the clinical setting for medical education.

So what did we learn? We should think of microlearning as moments when you turn to your smartphone or tablet in order to discover something, answer a question, or complete a task. These are moments when decisions are made and knowledge is reinforced. The goal is to capture these moments and fill them with essential pieces of information.

We offer these suggestions as a place to start. The microlearning platform allows for the collection of data on the interaction between user and course content. The data collected can be used for continuous quality improvement of the curriculum. Microlearning is a dynamic platform where creative ideas are encouraged and a multi-disciplinary approach is valuable to keeping an audience engaged. In the future, we hope to be able to correlate microlearning courses to provider performance and measurable patient outcomes.
 

Dr. Mercado is medical director at Alice Peck Day Memorial Hospital, and associate hospital epidemiologist, Dartmouth-Hitchcock Medical Center, both in Lebanon, N.H., and assistant professor at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Feng is a Fellow in the Leadership/Preventive Medicine Program in the Department of Internal Medicine at Dartmouth-Hitchcock Medical Center.

References

1. Duggan F and Banwell L. Constructing a model of effective information dissemination in a crisis. Information Research. 2004;9(3). Paper 178 [Available at http://InformationR.net/ir/9-3/paper178.html].

2. Filipe HP, et al. Microlearning to improve CPD learning objectives. Clin Teach. 2020 Dec;17(6):695-699. doi: 10.1111/tct.13208.

3. Hegerius A, et al. E-Learning in Pharmacovigilance: An Evaluation of Microlearning-Based Modules Developed by Uppsala Monitoring Centre. Drug Saf. 2020 Nov;43(11):1171-1180. doi: 10.1007/s40264-020-00981-w.

4. Orwoll B, et al. Gamification and Microlearning for Engagement With Quality Improvement (GAMEQI): A Bundled Digital Intervention for the Prevention of Central Line-Associated Bloodstream Infection. Am J Med Qual. Jan/Feb 2018;33(1):21-29. doi: 10.1177/1062860617706542.

The vast amounts of information generated this past year related to the COVID-19 pandemic was a feat of wonder – recommendations and guidelines on the hospital level and on the national level came in a flurry, more often overwhelming and confusing than clarifying for the frontline provider. In addition, “routine” hospital care for non-infected patients and improvement processes had to continue as we all dealt with the whirlwind of increasing COVID cases, torrents of new guidelines, and educating our trainees.

Thus, the individual-level question: how does a clinician stay engaged and distill the relentless stream of new information?

In Spring 2020, when the first patients with COVID were admitted, our hospital medicine section was tasked to create a surge plan. This included organizing, orienting, and educating off-service providers on how to become hospitalists. Undoubtedly, the call to arms for our center was heard, and many responded. However, backgrounds were diverse in specialty – clinicians and trainees from psychiatry, general surgery, and various fellowships all answered. It was an exhausting and inefficient effort to produce the material, hold webinars, and schedule training, especially for those who were more removed from a hospital medicine experience. We knew we had to come up with an alternative plan moving forward.

Thus, the systems-level question: how does a health care system educate its clinicians, or any other health care providers, when reallocation of their talents and skills is both necessary, time-sensitive, and occuring during a period where new information is constantly being produced and changing?

To reach the most clinicians as possible, with the most succinct and distilled information, we had to come up with a method to do so. Ultimately, in considering the situation at hand, we had to understand who we were as the provider of the information, and who the recipient would be. We would like to share the initiatives and processes by which we constructed our solution to the two questions – microlearning through hospital podcasting.
 

Learning from our health care colleagues

With the initial webinars and training sessions for our staff, we assessed our learners’ motivations and background in managing in a hospital medicine capacity. Overall, we discovered that our trainees and clinicians have an innate drive to learn; all of them recognized the importance of keeping up with evidence-based information. However, the difficulty highlighted was the individual time available to dedicate to acquiring new information and awareness of new information being available to the health care sector during the chaotic times of the pandemic.

From our section’s perspective, we had a difficulty with coordinating among multiple professional development groups within our hospital, cost, and resources to execute training. These difficulties between providing knowledge and receiving knowledge have already been expertly analyzed.¹

Parallel to this, the pedagogic paradigm shifts as we progress through our careers – the methods and skills we used in school contrast in many ways with those we use on a daily basis when it comes to learning. Instead of dedicating hours at a time to new challenges in our workflow or our interests, we watch videos, search retailers for product solutions, check our email correspondence, and peruse social media accounts several times a day. Information comes at us very quickly, but in small pieces.

One such innovation in pedagogy is the practice of microlearning. This refers to the use of small lesson modules and short-term activities intended to teach and reinforce concepts.² It is the opposite of “macrolearning,” which is the principle of dedicating reading material, structured coursework, and traditional knowledge evaluation in the form of exams to reinforce learning. Certainly, microlearning has other names as well – “just-in-time,” “just-enough,” and “micro-courses” are a few synonyms seen in the current literature. Though a highly relevant concept for our situation, translating it to an endproduct for our trainees and clinicians required more thought.
 

From theory to application

Microlearning allows for faster delivery of information – fewer things to write means shorter course distribution times, allowing the learner to respond faster to changing educational goals and training demands. Microlearning is flexible – “micro-courses” can give a broad overview of a subject or cover complex topics broken down into simple parts. In addition, micro-learning promotes retention of key concepts – given the length of each lesson, repetition of the topic by the learner is possible at any point in time. The whole experience is similar to checking your favorite social media application on your smartphone.

Certainly, many examples of the application of microlearning are available in the health care sector – pharmaceutical and nursing training both have utilized the theory extensively.^3-4 However, in many instances, individuals were still required to sit at a workstation to complete modules and lessons. We envisioned our application of microlearning to be “on-the-go,” without necessarily requiring a computer workstation or laptop to complete.

In thinking about how social media attracts and influences clinicians, many content creators on social media come to mind. In addition, most, if not all, have branched into various social media platforms – podcasting, blogging, YouTube, for example. In thinking about our colleagues and trainees, we wanted a platform that they could take on the go, without the need to focus their visual attention (such as while driving or running). Ultimately, we believe the podcast would be the best platform to disseminate our information.

Podcasting is not foreign to medicine. A variety of medical podcasts exist, whether produced by major medical journals or by various independent health care practitioners. Both, however, have their drawbacks – the podcasts created by major medical journals are typically a summary of the publication’s content and are less engaging. Alternatively, podcasts produced by independent creators are certainly engaging and entertaining, and have a wealth of information, but the line is often blurred between just that: education and entertainment. In both instances, there is no follow-up or feedback offered to the learner in the form of surveys, or other types of feedback, which is arguably an important piece in any form of pedagogy. Thus, we sought to strike a balance between the two forms for our purposes.
 

Process of two podcasts

Our section was aware of the two aims during the pandemic – (1) disseminate new information regarding COVID-19 to the rest of our staff members and trainees as quickly as possible, and (2) maintain and improve the current quality of care of our patients. Thus, we sought to apply the reach and efficiency of the podcasting medium to provide ongoing education and feedback with respect to these two aims.

“The Cure” podcast. We recognized the constant flow of new COVID-19 information and updates and we wanted to find a readily accessible platform to reach staff with timely updates. Our marketing & communications team later helped us realize that the content we wanted to share was relevant to our patients and the community, so we formatted the material to be practical and easily digestible- something that may help an individual make decisions at the bedside as well as have conversations at the dinner table. Most recently, we engaged with our human resources department to use our platform in orienting new hires with the goal of helping staff familiarize with the institutions policies, procedures, and job aids that keep staff and patients safe.

“Antibiotry” podcast. Prior to the COVID-19 pandemic, our antibiotic stewardship group noticed an increase in antibiotic use on our medical floors. This is monitored not only through internal metrics by our pharmacy department, but also via the SAAR (standardized antibiotic administration ratio). Both sources demonstrated an increase in antibiotic use, greater than expected. An initiative was formed between our hospital medicine and infectious disease sections, and our pharmacy department to raise awareness of this increase in use, provide education to our trainees, and to create systems solutions for clinicians.

Initially, we sought to hold in-person sessions once a month for our trainees. This was led by a senior resident at the time. Topics of discussion were geared towards clinical decision making regarding empiric antibiotic use on the hospital medicine service. At the same time, our team published empiric antibiotic use guidelines, accessible through our electronic medical record. In addition, the resident leader gave a voluntary survey at the end of the session to assess not only confidence of antibiotic use, but also baseline knowledge regarding antibiotics in various clinical scenarios. This survey was repeated at the end of the resident group’s month-long rotation. Altogether, each in-person session was no longer than 10 minutes.

Unfortunately, the initiative was just gaining momentum when the COVID-19 pandemic was declared. However, we sought to take this challenge and translate it into an opportunity.

We directed our focus towards stewardship during pandemic times. Initially, our resident leader sent out email primers, approximately 3-5 minute reads, as a substitute for the in-person sessions. Our primers’ uniqueness was in its incorporation of prescription pattern data that was developed by our resident leader and our initiative’s data analyst. In doing so, we provided professional feedback regarding our antibiotic use based on the clinical indication. This was a powerful tool to not only engage our learners and staff clinicians, but also as a benchmarking tool for continued quality improvement.

But email primers are not engaging, and despite the ubiquity of teleconferencing, it was difficult to ask our housestaff to break from their morning rounds for a 10 minute tele-meeting. Thus, we devised a podcast method of education – 5-10 minute audio clips with conversation regarding a topic of discussion. This way, our trainees and learners can access episodes of education on their own time throughout the pandemic without disrupting their workflow. Given the brevity of, but high-yield content in, each episode, it would not only be convenient for listeners to access and repeat, but also for the podcaster (our resident leader) to create, as recording of the audio portion takes anywhere between 10-20 minutes for each episode, with postprocessing similarly fast.

The interdisciplinary nature of continued medical education cannot be stressed enough. With the help of our professional development team and their educators, we were able to centralize our podcast and attach surveys and additional graphics for each episode, if appropriate. This additional detail allowed for feedback, engagement with our learners, and the chance to provide additional educational points, if the learner was interested. Given the integrated nature of this platform, quality metrics could easily be recorded in the form of “click” data and various other more conventional metrics, such as listener counts and the duration of each podcast played.
 

Future applications and initiatives

Thus far, we have had great success in the reception and use of both podcasts within our institution as an application of microlearning. “The Cure” has been widely listened to by all hospital staff from various services; it has caught the attention of state-wide radio programs, and plans to expand it into the community are being discussed.

As for “Antibiotry” podcast, the concept has been lauded by our medical educators. Given its centralization within our institution, we are able to publish institution-based data as a form of professional and educational feedback to our trainees and staff physicians. This is currently coupled with the development of a provider dashboard, visualizing antibiotic prescriptions and narrowing patterns of practice within our medicine department. We plan to expand “Antibiotry” to other services at the hospital.

For both podcasts, the steps it took to achieve the final product from the microlearning concept were possible through a combination of institutional need and a motivated team. We are fortunate to have highly energetic individuals, making the coordination and planning with our hospitalists, various sub-specialists, and professional development teams straightforward. As the team grows with more individuals interested in the initiatives, keen insight into interests, individual clinical expertise, presentation skills, and technical skills ought to be carefully weighed to sustain our podcasts most efficiently, and perhaps expand them through different social media platforms.

Our objective for sustainability is through the continued outreach to and recruitment of residents and medical students, who can play key roles in the development of future projects related to these educational innovations. Both microlearning podcasts were developed through the initial planning, trial and error, and execution by two resident leaders. Their initiative and motivation to educate our institution through these platforms were highly unique; their pathfinding set the foundation for sustainability and expansion to other services.

Of course, one of the key measures we would like to investigate is whether our microlearning platform translates to improved patient outcomes. Regarding “Antibiotry,” we hope to see a decrease in unnecessary broad-spectrum antibiotic use by drawing attention to clinician practice patterns. Quality and outcome metrics will continue to be developed and measured. In addition to patient care metrics, further investigation of pedagogical metrics will be conducted, especially in the evolving realm of graduate and continuing medical education.

Measuring educational quality is neither a new ethical nor philosophical debate – neither does it carry a definitive answer. Further help from education experts may be needed to assess the quality of the information provided and its impact on our learners.
 

Conclusion

Medicine is ever-changing – the guidelines and criteria for patient care and pathology that we learned in medical school have likely changed. There is no single “best” method of learning new information in medicine, simply due to the breadth and volume of such information generated on a daily basis. This poses both a challenge for present-day clinicians and trainees, and a stimulus for change in the methods of acquiring, absorbing, and applying new information to clinical decision making and practice.

We have found that podcasting is a well-received medium of information transfer that is convenient for both the learner and the content creator. Through the podcast format, we were able to distill non-engaging pieces of education and information and transform them into short-duration lessons that the learner can listen to at their own convenience. This proved to be especially handy during the chaos of the pandemic, not only for dissemination of information regarding the management of COVID-19, but also for sustaining quality improvement goals within our institution.

Further investigation on patient outcomes and information quality are the planned next steps. In addition, expansion of other microlearning media, such as group SMS texting, YouTube videos, and Twitter, ought to be considered. Though many publications discuss the theory, potential benefits, and predicted pitfalls of microlearning, few assess the real-world application of microlearning to the clinical setting for medical education.

So what did we learn? We should think of microlearning as moments when you turn to your smartphone or tablet in order to discover something, answer a question, or complete a task. These are moments when decisions are made and knowledge is reinforced. The goal is to capture these moments and fill them with essential pieces of information.

We offer these suggestions as a place to start. The microlearning platform allows for the collection of data on the interaction between user and course content. The data collected can be used for continuous quality improvement of the curriculum. Microlearning is a dynamic platform where creative ideas are encouraged and a multi-disciplinary approach is valuable to keeping an audience engaged. In the future, we hope to be able to correlate microlearning courses to provider performance and measurable patient outcomes.
 

Dr. Mercado is medical director at Alice Peck Day Memorial Hospital, and associate hospital epidemiologist, Dartmouth-Hitchcock Medical Center, both in Lebanon, N.H., and assistant professor at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Feng is a Fellow in the Leadership/Preventive Medicine Program in the Department of Internal Medicine at Dartmouth-Hitchcock Medical Center.

References

1. Duggan F and Banwell L. Constructing a model of effective information dissemination in a crisis. Information Research. 2004;9(3). Paper 178 [Available at http://InformationR.net/ir/9-3/paper178.html].

2. Filipe HP, et al. Microlearning to improve CPD learning objectives. Clin Teach. 2020 Dec;17(6):695-699. doi: 10.1111/tct.13208.

3. Hegerius A, et al. E-Learning in Pharmacovigilance: An Evaluation of Microlearning-Based Modules Developed by Uppsala Monitoring Centre. Drug Saf. 2020 Nov;43(11):1171-1180. doi: 10.1007/s40264-020-00981-w.

4. Orwoll B, et al. Gamification and Microlearning for Engagement With Quality Improvement (GAMEQI): A Bundled Digital Intervention for the Prevention of Central Line-Associated Bloodstream Infection. Am J Med Qual. Jan/Feb 2018;33(1):21-29. doi: 10.1177/1062860617706542.

The vast amounts of information generated this past year related to the COVID-19 pandemic was a feat of wonder – recommendations and guidelines on the hospital level and on the national level came in a flurry, more often overwhelming and confusing than clarifying for the frontline provider. In addition, “routine” hospital care for non-infected patients and improvement processes had to continue as we all dealt with the whirlwind of increasing COVID cases, torrents of new guidelines, and educating our trainees.

Thus, the individual-level question: how does a clinician stay engaged and distill the relentless stream of new information?

In Spring 2020, when the first patients with COVID were admitted, our hospital medicine section was tasked to create a surge plan. This included organizing, orienting, and educating off-service providers on how to become hospitalists. Undoubtedly, the call to arms for our center was heard, and many responded. However, backgrounds were diverse in specialty – clinicians and trainees from psychiatry, general surgery, and various fellowships all answered. It was an exhausting and inefficient effort to produce the material, hold webinars, and schedule training, especially for those who were more removed from a hospital medicine experience. We knew we had to come up with an alternative plan moving forward.

Thus, the systems-level question: how does a health care system educate its clinicians, or any other health care providers, when reallocation of their talents and skills is both necessary, time-sensitive, and occuring during a period where new information is constantly being produced and changing?

To reach the most clinicians as possible, with the most succinct and distilled information, we had to come up with a method to do so. Ultimately, in considering the situation at hand, we had to understand who we were as the provider of the information, and who the recipient would be. We would like to share the initiatives and processes by which we constructed our solution to the two questions – microlearning through hospital podcasting.
 

Learning from our health care colleagues

With the initial webinars and training sessions for our staff, we assessed our learners’ motivations and background in managing in a hospital medicine capacity. Overall, we discovered that our trainees and clinicians have an innate drive to learn; all of them recognized the importance of keeping up with evidence-based information. However, the difficulty highlighted was the individual time available to dedicate to acquiring new information and awareness of new information being available to the health care sector during the chaotic times of the pandemic.

From our section’s perspective, we had a difficulty with coordinating among multiple professional development groups within our hospital, cost, and resources to execute training. These difficulties between providing knowledge and receiving knowledge have already been expertly analyzed.¹

Parallel to this, the pedagogic paradigm shifts as we progress through our careers – the methods and skills we used in school contrast in many ways with those we use on a daily basis when it comes to learning. Instead of dedicating hours at a time to new challenges in our workflow or our interests, we watch videos, search retailers for product solutions, check our email correspondence, and peruse social media accounts several times a day. Information comes at us very quickly, but in small pieces.

One such innovation in pedagogy is the practice of microlearning. This refers to the use of small lesson modules and short-term activities intended to teach and reinforce concepts.² It is the opposite of “macrolearning,” which is the principle of dedicating reading material, structured coursework, and traditional knowledge evaluation in the form of exams to reinforce learning. Certainly, microlearning has other names as well – “just-in-time,” “just-enough,” and “micro-courses” are a few synonyms seen in the current literature. Though a highly relevant concept for our situation, translating it to an endproduct for our trainees and clinicians required more thought.
 

From theory to application

Microlearning allows for faster delivery of information – fewer things to write means shorter course distribution times, allowing the learner to respond faster to changing educational goals and training demands. Microlearning is flexible – “micro-courses” can give a broad overview of a subject or cover complex topics broken down into simple parts. In addition, micro-learning promotes retention of key concepts – given the length of each lesson, repetition of the topic by the learner is possible at any point in time. The whole experience is similar to checking your favorite social media application on your smartphone.

Certainly, many examples of the application of microlearning are available in the health care sector – pharmaceutical and nursing training both have utilized the theory extensively.^3-4 However, in many instances, individuals were still required to sit at a workstation to complete modules and lessons. We envisioned our application of microlearning to be “on-the-go,” without necessarily requiring a computer workstation or laptop to complete.

In thinking about how social media attracts and influences clinicians, many content creators on social media come to mind. In addition, most, if not all, have branched into various social media platforms – podcasting, blogging, YouTube, for example. In thinking about our colleagues and trainees, we wanted a platform that they could take on the go, without the need to focus their visual attention (such as while driving or running). Ultimately, we believe the podcast would be the best platform to disseminate our information.

Podcasting is not foreign to medicine. A variety of medical podcasts exist, whether produced by major medical journals or by various independent health care practitioners. Both, however, have their drawbacks – the podcasts created by major medical journals are typically a summary of the publication’s content and are less engaging. Alternatively, podcasts produced by independent creators are certainly engaging and entertaining, and have a wealth of information, but the line is often blurred between just that: education and entertainment. In both instances, there is no follow-up or feedback offered to the learner in the form of surveys, or other types of feedback, which is arguably an important piece in any form of pedagogy. Thus, we sought to strike a balance between the two forms for our purposes.
 

Process of two podcasts

Our section was aware of the two aims during the pandemic – (1) disseminate new information regarding COVID-19 to the rest of our staff members and trainees as quickly as possible, and (2) maintain and improve the current quality of care of our patients. Thus, we sought to apply the reach and efficiency of the podcasting medium to provide ongoing education and feedback with respect to these two aims.

“The Cure” podcast. We recognized the constant flow of new COVID-19 information and updates and we wanted to find a readily accessible platform to reach staff with timely updates. Our marketing & communications team later helped us realize that the content we wanted to share was relevant to our patients and the community, so we formatted the material to be practical and easily digestible- something that may help an individual make decisions at the bedside as well as have conversations at the dinner table. Most recently, we engaged with our human resources department to use our platform in orienting new hires with the goal of helping staff familiarize with the institutions policies, procedures, and job aids that keep staff and patients safe.

“Antibiotry” podcast. Prior to the COVID-19 pandemic, our antibiotic stewardship group noticed an increase in antibiotic use on our medical floors. This is monitored not only through internal metrics by our pharmacy department, but also via the SAAR (standardized antibiotic administration ratio). Both sources demonstrated an increase in antibiotic use, greater than expected. An initiative was formed between our hospital medicine and infectious disease sections, and our pharmacy department to raise awareness of this increase in use, provide education to our trainees, and to create systems solutions for clinicians.

Initially, we sought to hold in-person sessions once a month for our trainees. This was led by a senior resident at the time. Topics of discussion were geared towards clinical decision making regarding empiric antibiotic use on the hospital medicine service. At the same time, our team published empiric antibiotic use guidelines, accessible through our electronic medical record. In addition, the resident leader gave a voluntary survey at the end of the session to assess not only confidence of antibiotic use, but also baseline knowledge regarding antibiotics in various clinical scenarios. This survey was repeated at the end of the resident group’s month-long rotation. Altogether, each in-person session was no longer than 10 minutes.

Unfortunately, the initiative was just gaining momentum when the COVID-19 pandemic was declared. However, we sought to take this challenge and translate it into an opportunity.

We directed our focus towards stewardship during pandemic times. Initially, our resident leader sent out email primers, approximately 3-5 minute reads, as a substitute for the in-person sessions. Our primers’ uniqueness was in its incorporation of prescription pattern data that was developed by our resident leader and our initiative’s data analyst. In doing so, we provided professional feedback regarding our antibiotic use based on the clinical indication. This was a powerful tool to not only engage our learners and staff clinicians, but also as a benchmarking tool for continued quality improvement.

But email primers are not engaging, and despite the ubiquity of teleconferencing, it was difficult to ask our housestaff to break from their morning rounds for a 10 minute tele-meeting. Thus, we devised a podcast method of education – 5-10 minute audio clips with conversation regarding a topic of discussion. This way, our trainees and learners can access episodes of education on their own time throughout the pandemic without disrupting their workflow. Given the brevity of, but high-yield content in, each episode, it would not only be convenient for listeners to access and repeat, but also for the podcaster (our resident leader) to create, as recording of the audio portion takes anywhere between 10-20 minutes for each episode, with postprocessing similarly fast.

The interdisciplinary nature of continued medical education cannot be stressed enough. With the help of our professional development team and their educators, we were able to centralize our podcast and attach surveys and additional graphics for each episode, if appropriate. This additional detail allowed for feedback, engagement with our learners, and the chance to provide additional educational points, if the learner was interested. Given the integrated nature of this platform, quality metrics could easily be recorded in the form of “click” data and various other more conventional metrics, such as listener counts and the duration of each podcast played.
 

Future applications and initiatives

Thus far, we have had great success in the reception and use of both podcasts within our institution as an application of microlearning. “The Cure” has been widely listened to by all hospital staff from various services; it has caught the attention of state-wide radio programs, and plans to expand it into the community are being discussed.

As for “Antibiotry” podcast, the concept has been lauded by our medical educators. Given its centralization within our institution, we are able to publish institution-based data as a form of professional and educational feedback to our trainees and staff physicians. This is currently coupled with the development of a provider dashboard, visualizing antibiotic prescriptions and narrowing patterns of practice within our medicine department. We plan to expand “Antibiotry” to other services at the hospital.

For both podcasts, the steps it took to achieve the final product from the microlearning concept were possible through a combination of institutional need and a motivated team. We are fortunate to have highly energetic individuals, making the coordination and planning with our hospitalists, various sub-specialists, and professional development teams straightforward. As the team grows with more individuals interested in the initiatives, keen insight into interests, individual clinical expertise, presentation skills, and technical skills ought to be carefully weighed to sustain our podcasts most efficiently, and perhaps expand them through different social media platforms.

Our objective for sustainability is through the continued outreach to and recruitment of residents and medical students, who can play key roles in the development of future projects related to these educational innovations. Both microlearning podcasts were developed through the initial planning, trial and error, and execution by two resident leaders. Their initiative and motivation to educate our institution through these platforms were highly unique; their pathfinding set the foundation for sustainability and expansion to other services.

Of course, one of the key measures we would like to investigate is whether our microlearning platform translates to improved patient outcomes. Regarding “Antibiotry,” we hope to see a decrease in unnecessary broad-spectrum antibiotic use by drawing attention to clinician practice patterns. Quality and outcome metrics will continue to be developed and measured. In addition to patient care metrics, further investigation of pedagogical metrics will be conducted, especially in the evolving realm of graduate and continuing medical education.

Measuring educational quality is neither a new ethical nor philosophical debate – neither does it carry a definitive answer. Further help from education experts may be needed to assess the quality of the information provided and its impact on our learners.
 

Conclusion

Medicine is ever-changing – the guidelines and criteria for patient care and pathology that we learned in medical school have likely changed. There is no single “best” method of learning new information in medicine, simply due to the breadth and volume of such information generated on a daily basis. This poses both a challenge for present-day clinicians and trainees, and a stimulus for change in the methods of acquiring, absorbing, and applying new information to clinical decision making and practice.

We have found that podcasting is a well-received medium of information transfer that is convenient for both the learner and the content creator. Through the podcast format, we were able to distill non-engaging pieces of education and information and transform them into short-duration lessons that the learner can listen to at their own convenience. This proved to be especially handy during the chaos of the pandemic, not only for dissemination of information regarding the management of COVID-19, but also for sustaining quality improvement goals within our institution.

Further investigation on patient outcomes and information quality are the planned next steps. In addition, expansion of other microlearning media, such as group SMS texting, YouTube videos, and Twitter, ought to be considered. Though many publications discuss the theory, potential benefits, and predicted pitfalls of microlearning, few assess the real-world application of microlearning to the clinical setting for medical education.

So what did we learn? We should think of microlearning as moments when you turn to your smartphone or tablet in order to discover something, answer a question, or complete a task. These are moments when decisions are made and knowledge is reinforced. The goal is to capture these moments and fill them with essential pieces of information.

We offer these suggestions as a place to start. The microlearning platform allows for the collection of data on the interaction between user and course content. The data collected can be used for continuous quality improvement of the curriculum. Microlearning is a dynamic platform where creative ideas are encouraged and a multi-disciplinary approach is valuable to keeping an audience engaged. In the future, we hope to be able to correlate microlearning courses to provider performance and measurable patient outcomes.
 

Dr. Mercado is medical director at Alice Peck Day Memorial Hospital, and associate hospital epidemiologist, Dartmouth-Hitchcock Medical Center, both in Lebanon, N.H., and assistant professor at the Geisel School of Medicine at Dartmouth, Hanover, N.H. Dr. Feng is a Fellow in the Leadership/Preventive Medicine Program in the Department of Internal Medicine at Dartmouth-Hitchcock Medical Center.

References

1. Duggan F and Banwell L. Constructing a model of effective information dissemination in a crisis. Information Research. 2004;9(3). Paper 178 [Available at http://InformationR.net/ir/9-3/paper178.html].

2. Filipe HP, et al. Microlearning to improve CPD learning objectives. Clin Teach. 2020 Dec;17(6):695-699. doi: 10.1111/tct.13208.

3. Hegerius A, et al. E-Learning in Pharmacovigilance: An Evaluation of Microlearning-Based Modules Developed by Uppsala Monitoring Centre. Drug Saf. 2020 Nov;43(11):1171-1180. doi: 10.1007/s40264-020-00981-w.

4. Orwoll B, et al. Gamification and Microlearning for Engagement With Quality Improvement (GAMEQI): A Bundled Digital Intervention for the Prevention of Central Line-Associated Bloodstream Infection. Am J Med Qual. Jan/Feb 2018;33(1):21-29. doi: 10.1177/1062860617706542.

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?

Mayo Clinic findings on radio communication used by mobile phones

Once our flight landed, we did some research to answer our initial question about personal communication technology and its ability to interfere with sensitive electronic devices. Specifically, we wanted to know whether radio communication used by mobile phones could affect the operation of medical equipment, potentially leading to dire consequences for patients. Spoiler alert: There is very little evidence that this can occur. In fact, a well-documented study performed by the Mayo Clinic in 2007 found interference in 0 out of 300 tests performed. To quote the authors, “the incidence of clinically important interference was 0%.”

We could find no other studies since 2007 that strongly contradict Mayo’s findings, except for several anecdotal reports and articles that postulate the theoretical possibility.

This is confirmed by the American Heart Association, who maintains a list of devices that may interfere with ICDs and pacemakers on their website. According to the AHA, “wireless transmissions from the antennae of phones available in the United States are a very small risk to ICDs and even less of a risk for pacemakers.” And in case you’re wondering, the story is quite similar for airplanes as well.

The latest publication from NASA’s Aviation Safety Reporting System (ASRS) documents incidents related to personal electronic devices during air travel. Most involve smoke production – or even small fires – caused by malfunctioning phone batteries during charging. Only a few entries reference wireless interference, and these were all minor and unconfirmed events. As with health care environments, airplanes don’t appear to face significant risks from radio interference. But that doesn’t mean personal electronics are completely harmless to patients.

Smartphones’ risks to patient with cardiac devices

On May 13 of 2021, the FDA issued a warning to cardiac patients about their smart phones and smart watches. Many current personal electronic devices and accessories are equipped with strong magnets, such as those contained in the “MagSafe” connector on the iPhone 12, that can deactivate pacemakers and implanted cardiac defibrillators. These medical devices are designed to be manipulated by magnets for diagnostic and therapeutic purposes, but strong magnetic fields can disable them unintentionally, leading to catastrophic results.

Apple and other manufacturers have acknowledged this risk and recommend that smartphones and other devices be kept at least 6 inches from cardiac devices. Given the ubiquity of offending products, it is also imperative that we warn our patients about this risk to their physical wellbeing.

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?

Mayo Clinic findings on radio communication used by mobile phones

Once our flight landed, we did some research to answer our initial question about personal communication technology and its ability to interfere with sensitive electronic devices. Specifically, we wanted to know whether radio communication used by mobile phones could affect the operation of medical equipment, potentially leading to dire consequences for patients. Spoiler alert: There is very little evidence that this can occur. In fact, a well-documented study performed by the Mayo Clinic in 2007 found interference in 0 out of 300 tests performed. To quote the authors, “the incidence of clinically important interference was 0%.”

We could find no other studies since 2007 that strongly contradict Mayo’s findings, except for several anecdotal reports and articles that postulate the theoretical possibility.

This is confirmed by the American Heart Association, who maintains a list of devices that may interfere with ICDs and pacemakers on their website. According to the AHA, “wireless transmissions from the antennae of phones available in the United States are a very small risk to ICDs and even less of a risk for pacemakers.” And in case you’re wondering, the story is quite similar for airplanes as well.

The latest publication from NASA’s Aviation Safety Reporting System (ASRS) documents incidents related to personal electronic devices during air travel. Most involve smoke production – or even small fires – caused by malfunctioning phone batteries during charging. Only a few entries reference wireless interference, and these were all minor and unconfirmed events. As with health care environments, airplanes don’t appear to face significant risks from radio interference. But that doesn’t mean personal electronics are completely harmless to patients.

Smartphones’ risks to patient with cardiac devices

On May 13 of 2021, the FDA issued a warning to cardiac patients about their smart phones and smart watches. Many current personal electronic devices and accessories are equipped with strong magnets, such as those contained in the “MagSafe” connector on the iPhone 12, that can deactivate pacemakers and implanted cardiac defibrillators. These medical devices are designed to be manipulated by magnets for diagnostic and therapeutic purposes, but strong magnetic fields can disable them unintentionally, leading to catastrophic results.

Apple and other manufacturers have acknowledged this risk and recommend that smartphones and other devices be kept at least 6 inches from cardiac devices. Given the ubiquity of offending products, it is also imperative that we warn our patients about this risk to their physical wellbeing.

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Over the 10 years we’ve been writing this column, we have often found inspiration for topics while traveling – especially while flying. This is not just because of the idle time spent in the air, but instead because of the many ways that air travel and health care experiences are similar. Both industries focus heavily on safety, are tightly regulated, and employ highly trained individuals.

Consumers may recognize the similarities as well – health care and air travel are both well-known for long waits, uncertainty, and implicit risk. Both sectors are also notorious drivers of innovation, constantly leveraging new technologies in pursuit of better outcomes and experiences. Occasionally, however, advancements in technology can present unforeseen challenges and even compromise safety, with the potential to produce unexpected consequences.

A familiar reminder of this potential was provided to us at the commencement of a recent flight, when we were instructed to turn off our personal electronic devices or flip them into “airplane mode.” This same admonishment is often given to patients and visitors in health care settings – everywhere from clinic waiting rooms to intensive care units – though the reason for this is typically left vague. This got us thinking. We wondered, what is the real risk of smart phones in medicine , or aviation, for that matter. More importantly, what other emerging technologies have the potential to create issues we may not have anticipated?

Mayo Clinic findings on radio communication used by mobile phones

Once our flight landed, we did some research to answer our initial question about personal communication technology and its ability to interfere with sensitive electronic devices. Specifically, we wanted to know whether radio communication used by mobile phones could affect the operation of medical equipment, potentially leading to dire consequences for patients. Spoiler alert: There is very little evidence that this can occur. In fact, a well-documented study performed by the Mayo Clinic in 2007 found interference in 0 out of 300 tests performed. To quote the authors, “the incidence of clinically important interference was 0%.”

We could find no other studies since 2007 that strongly contradict Mayo’s findings, except for several anecdotal reports and articles that postulate the theoretical possibility.

This is confirmed by the American Heart Association, who maintains a list of devices that may interfere with ICDs and pacemakers on their website. According to the AHA, “wireless transmissions from the antennae of phones available in the United States are a very small risk to ICDs and even less of a risk for pacemakers.” And in case you’re wondering, the story is quite similar for airplanes as well.

The latest publication from NASA’s Aviation Safety Reporting System (ASRS) documents incidents related to personal electronic devices during air travel. Most involve smoke production – or even small fires – caused by malfunctioning phone batteries during charging. Only a few entries reference wireless interference, and these were all minor and unconfirmed events. As with health care environments, airplanes don’t appear to face significant risks from radio interference. But that doesn’t mean personal electronics are completely harmless to patients.

Smartphones’ risks to patient with cardiac devices

On May 13 of 2021, the FDA issued a warning to cardiac patients about their smart phones and smart watches. Many current personal electronic devices and accessories are equipped with strong magnets, such as those contained in the “MagSafe” connector on the iPhone 12, that can deactivate pacemakers and implanted cardiac defibrillators. These medical devices are designed to be manipulated by magnets for diagnostic and therapeutic purposes, but strong magnetic fields can disable them unintentionally, leading to catastrophic results.

Apple and other manufacturers have acknowledged this risk and recommend that smartphones and other devices be kept at least 6 inches from cardiac devices. Given the ubiquity of offending products, it is also imperative that we warn our patients about this risk to their physical wellbeing.

Dr. Notte is a family physician and chief medical officer of Abington (Pa.) Hospital–Jefferson Health. Dr. Skolnik is professor of family and community medicine at Sidney Kimmel Medical College, Philadelphia, and associate director of the family medicine residency program at Abington Hospital–Jefferson Health. They have no conflicts related to the content of this piece.

Editor’s note: Prior authorization has been flagged as the biggest payer-related cause of stress for U.S. oncologists. In one survey, 75% said prior authorization was their biggest burden, followed by coverage denials and appeals (62%). Another survey found that practices spent on average 16.4 hours a week dealing with prior authorizations.

In the 16 years since I went into practice as a medical oncologist, the issue of prior authorization has become a nightmare.

Around 5% of my emails every day are from insurance companies denying my patients the treatments I have recommended. A part of every day is spent worrying about how I’m going to cover my patients’ therapy and what I need to order to make sure it doesn’t get delayed.

Many doctors are retiring because they don’t want to deal with this anymore. There are many times that I have thought about quitting for this reason. A partner of mine had a heart attack last year. He’s a few years older than I am – in his mid-50s – and that scared me. I actually had a CT angiogram just to make sure. They told me my heart is fine, but I worry because of all these frustrations every day. And I’m not alone. For every doctor I work with, it’s the same story, and it’s just ridiculous.

For example, I had a patient with a huge breast mass. My nurse got me the prior authorization for an emergency biopsy. I got back the results for estrogen and progesterone receptor status, but not the HER2-neu results because that test required another authorization.

Authorization shouldn’t be required for every single step. I understand if maybe you need to get an authorization to do something outside the standard of care or something that is unique or unheard of, but HER2-neu biopsy is standard of care and should not require additional authorization.

And the sad part is, that patient turned out to be HER2-neu positive. She lost 4 weeks just waiting for an authorization of a test that should be a no-brainer.

We cannot even do a blood count in our office before getting authorization from some insurances. This is a very important test when we give chemotherapy, and it’s very cheap.

And then another nightmare is if you want to give a patient growth factors when you see their blood count is going down. Sometimes the insurance company will say, “When they get neutropenic fever, we’ll allow it with the next cycle.” Why do I have to wait until the patient develops such a problem to start with a treatment that could avoid it? They may end up in the hospital.

I think I’m one of the more conservative doctors; I try to do everything scientifically and only order a test or a treatment if it’s indicated. But sometimes this guidance costs more money. For example, an insurance company may say to order a CT scan first and if you don’t find your answer, then get a PET scan.

So I order a CT scan, knowing it’s not going to help, and then I tell them, “Now I need a PET scan.” That’s another week delay and an extra cost that I don’t want the system to incur.

I’ve even had some issues with lung screening scans for smokers. This screening has reduced mortality by 20%; it should be a no-brainer to encourage smokers to do it because many of them may not even need chemotherapy if you find early-stage lung cancer. And the screening is not expensive, you can do it for $90 to $100. So why do we have to get authorization for that?

Sometimes I push back and request a “peer-to-peer,” where you challenge the decision of the insurance company and speak to one of their doctors. Out of 10 doctors, maybe three or four will do the peer-to-peer. The rest will give up because it’s so frustrating.

In one case, I wanted to modify a standard regimen and give only two out of three drugs because I thought the third would be too toxic. But the insurance company wouldn’t approve the regimen because the guidelines say you have to give three drugs.

Guidelines are guidance, they should not dictate how you treat an individual patient – there should be some allowance in there for a doctor’s discretion. If not, why do we even need doctors? We could just follow treatment regimens dictated by computers. They have to allow me to personalize the care that my patient deserves and make changes so that the treatment can be tolerated.

But then, I get that one patient whom I feel I really helped and I realize, “Okay, I can help more people.”

I had this one patient, a young, 40-year-old nurse with breast cancer – also HER2-neu positive. She’d had her surgery and finished her adjuvant chemotherapy. One of the things that you do as standard of care, after a year of trastuzumab, is you start them on neratinib. There are studies that show it improves progression-free survival if you give them an extra year of this drug as an adjuvant.

I prescribed the neratinib, but the insurance company denied it because the patient “did not have positive lymph nodes and was not considered high risk.” I told them, “That’s BS, that’s not what the indication is for.” I asked for a peer-to-peer and they said the policy did not allow for peer-to-peer. So, I made a big fuss about it. We appealed, and I finally spoke to a pharmacist who worked for the insurance company. I told him, “Why did you guys deny this? It’s standard of care.” He said, “Oh, I agree with you, this will be approved. And actually, we’re going to change the policy now.”

When that pharmacist told me they were going to change the policy, it was like someone gave me 1 million dollars. Because, you know what? I didn’t just help my patient; now other patients will also get it. The hope is that if you keep fighting for something, they will change it.

I think every doctor wants to do the best for their patients. It’s not like they don’t want to, but really, I am fortunate that I have the means to do it. We’re a big practice and we have dedicated staff who can help.

If you’re a small practice, it’s almost impossible to deal with this. I have two nurse practitioners, and a lot of their work is filling out paperwork for insurance companies.

We had a colleague, a solo practitioner, who would send us his patients with complicated therapies, because he couldn’t afford the time or the effort or the risk of not getting reimbursed. His practice could have paid out $100,000 for drugs and not get a reimbursement for a few months.

Even when an insurance company does give the preauthorization, there’s always this disclaimer that it doesn’t guarantee payment. If they find in the future that your patient didn’t meet the criteria, they can still deny payment.

If the insurers refuse coverage, we really work hard at getting patients free drugs, and most of the time, we manage to do that. We either look to charitable organizations, like the Leukemia and Lymphoma Society, or we look for rare disease societies or we go to the pharmaceutical company.

For really expensive drugs, pharmaceutical companies have a program where you can enroll the patient and they can help copay or even cover the drug. For less expensive drugs, it might not be a big problem, but for a drug that can cost $18,000 to $20,000 a month, that’s a big risk to take.

It’s confusing for patients, too. They get angry and frustrated, and that’s not good for their treatment, because attitude and psychology are very important. Sometimes they yell at us because they think it’s our fault. I encourage them to call their insurance companies themselves, and some of them do.

I don’t do it with every patient, but there are some more educated patients who are advocates, and if their condition is stable, I do encourage them to call their senators or congressmen or congresswomen to complain.

I don’t mind treating complicated patients. I don’t want to say I enjoy it, but I like challenges. That’s my field, that’s medicine, that’s what I’m supposed to do. But it’s really sad and frustrating that, when you want to treat a patient, you first have to look at their insurance to see how much care you can actually give them.

Maen Hussein, MD, is physician director of finance at Florida Cancer Specialists and Research Institute, Fort Myers. He is a board member of the Florida Cancer Specialists Foundation and sits on the board of directors for the Florida Society of Clinical Oncology.

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

Editor’s note: Prior authorization has been flagged as the biggest payer-related cause of stress for U.S. oncologists. In one survey, 75% said prior authorization was their biggest burden, followed by coverage denials and appeals (62%). Another survey found that practices spent on average 16.4 hours a week dealing with prior authorizations.

In the 16 years since I went into practice as a medical oncologist, the issue of prior authorization has become a nightmare.

Around 5% of my emails every day are from insurance companies denying my patients the treatments I have recommended. A part of every day is spent worrying about how I’m going to cover my patients’ therapy and what I need to order to make sure it doesn’t get delayed.

Many doctors are retiring because they don’t want to deal with this anymore. There are many times that I have thought about quitting for this reason. A partner of mine had a heart attack last year. He’s a few years older than I am – in his mid-50s – and that scared me. I actually had a CT angiogram just to make sure. They told me my heart is fine, but I worry because of all these frustrations every day. And I’m not alone. For every doctor I work with, it’s the same story, and it’s just ridiculous.

For example, I had a patient with a huge breast mass. My nurse got me the prior authorization for an emergency biopsy. I got back the results for estrogen and progesterone receptor status, but not the HER2-neu results because that test required another authorization.

Authorization shouldn’t be required for every single step. I understand if maybe you need to get an authorization to do something outside the standard of care or something that is unique or unheard of, but HER2-neu biopsy is standard of care and should not require additional authorization.

And the sad part is, that patient turned out to be HER2-neu positive. She lost 4 weeks just waiting for an authorization of a test that should be a no-brainer.

We cannot even do a blood count in our office before getting authorization from some insurances. This is a very important test when we give chemotherapy, and it’s very cheap.

And then another nightmare is if you want to give a patient growth factors when you see their blood count is going down. Sometimes the insurance company will say, “When they get neutropenic fever, we’ll allow it with the next cycle.” Why do I have to wait until the patient develops such a problem to start with a treatment that could avoid it? They may end up in the hospital.

I think I’m one of the more conservative doctors; I try to do everything scientifically and only order a test or a treatment if it’s indicated. But sometimes this guidance costs more money. For example, an insurance company may say to order a CT scan first and if you don’t find your answer, then get a PET scan.

So I order a CT scan, knowing it’s not going to help, and then I tell them, “Now I need a PET scan.” That’s another week delay and an extra cost that I don’t want the system to incur.

I’ve even had some issues with lung screening scans for smokers. This screening has reduced mortality by 20%; it should be a no-brainer to encourage smokers to do it because many of them may not even need chemotherapy if you find early-stage lung cancer. And the screening is not expensive, you can do it for $90 to $100. So why do we have to get authorization for that?

Sometimes I push back and request a “peer-to-peer,” where you challenge the decision of the insurance company and speak to one of their doctors. Out of 10 doctors, maybe three or four will do the peer-to-peer. The rest will give up because it’s so frustrating.

In one case, I wanted to modify a standard regimen and give only two out of three drugs because I thought the third would be too toxic. But the insurance company wouldn’t approve the regimen because the guidelines say you have to give three drugs.

Guidelines are guidance, they should not dictate how you treat an individual patient – there should be some allowance in there for a doctor’s discretion. If not, why do we even need doctors? We could just follow treatment regimens dictated by computers. They have to allow me to personalize the care that my patient deserves and make changes so that the treatment can be tolerated.

But then, I get that one patient whom I feel I really helped and I realize, “Okay, I can help more people.”

I had this one patient, a young, 40-year-old nurse with breast cancer – also HER2-neu positive. She’d had her surgery and finished her adjuvant chemotherapy. One of the things that you do as standard of care, after a year of trastuzumab, is you start them on neratinib. There are studies that show it improves progression-free survival if you give them an extra year of this drug as an adjuvant.

I prescribed the neratinib, but the insurance company denied it because the patient “did not have positive lymph nodes and was not considered high risk.” I told them, “That’s BS, that’s not what the indication is for.” I asked for a peer-to-peer and they said the policy did not allow for peer-to-peer. So, I made a big fuss about it. We appealed, and I finally spoke to a pharmacist who worked for the insurance company. I told him, “Why did you guys deny this? It’s standard of care.” He said, “Oh, I agree with you, this will be approved. And actually, we’re going to change the policy now.”

When that pharmacist told me they were going to change the policy, it was like someone gave me 1 million dollars. Because, you know what? I didn’t just help my patient; now other patients will also get it. The hope is that if you keep fighting for something, they will change it.

I think every doctor wants to do the best for their patients. It’s not like they don’t want to, but really, I am fortunate that I have the means to do it. We’re a big practice and we have dedicated staff who can help.

If you’re a small practice, it’s almost impossible to deal with this. I have two nurse practitioners, and a lot of their work is filling out paperwork for insurance companies.

We had a colleague, a solo practitioner, who would send us his patients with complicated therapies, because he couldn’t afford the time or the effort or the risk of not getting reimbursed. His practice could have paid out $100,000 for drugs and not get a reimbursement for a few months.

Even when an insurance company does give the preauthorization, there’s always this disclaimer that it doesn’t guarantee payment. If they find in the future that your patient didn’t meet the criteria, they can still deny payment.

If the insurers refuse coverage, we really work hard at getting patients free drugs, and most of the time, we manage to do that. We either look to charitable organizations, like the Leukemia and Lymphoma Society, or we look for rare disease societies or we go to the pharmaceutical company.

For really expensive drugs, pharmaceutical companies have a program where you can enroll the patient and they can help copay or even cover the drug. For less expensive drugs, it might not be a big problem, but for a drug that can cost $18,000 to $20,000 a month, that’s a big risk to take.

It’s confusing for patients, too. They get angry and frustrated, and that’s not good for their treatment, because attitude and psychology are very important. Sometimes they yell at us because they think it’s our fault. I encourage them to call their insurance companies themselves, and some of them do.

I don’t do it with every patient, but there are some more educated patients who are advocates, and if their condition is stable, I do encourage them to call their senators or congressmen or congresswomen to complain.

I don’t mind treating complicated patients. I don’t want to say I enjoy it, but I like challenges. That’s my field, that’s medicine, that’s what I’m supposed to do. But it’s really sad and frustrating that, when you want to treat a patient, you first have to look at their insurance to see how much care you can actually give them.

Maen Hussein, MD, is physician director of finance at Florida Cancer Specialists and Research Institute, Fort Myers. He is a board member of the Florida Cancer Specialists Foundation and sits on the board of directors for the Florida Society of Clinical Oncology.

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

Editor’s note: Prior authorization has been flagged as the biggest payer-related cause of stress for U.S. oncologists. In one survey, 75% said prior authorization was their biggest burden, followed by coverage denials and appeals (62%). Another survey found that practices spent on average 16.4 hours a week dealing with prior authorizations.

In the 16 years since I went into practice as a medical oncologist, the issue of prior authorization has become a nightmare.

Around 5% of my emails every day are from insurance companies denying my patients the treatments I have recommended. A part of every day is spent worrying about how I’m going to cover my patients’ therapy and what I need to order to make sure it doesn’t get delayed.

Many doctors are retiring because they don’t want to deal with this anymore. There are many times that I have thought about quitting for this reason. A partner of mine had a heart attack last year. He’s a few years older than I am – in his mid-50s – and that scared me. I actually had a CT angiogram just to make sure. They told me my heart is fine, but I worry because of all these frustrations every day. And I’m not alone. For every doctor I work with, it’s the same story, and it’s just ridiculous.

For example, I had a patient with a huge breast mass. My nurse got me the prior authorization for an emergency biopsy. I got back the results for estrogen and progesterone receptor status, but not the HER2-neu results because that test required another authorization.

Authorization shouldn’t be required for every single step. I understand if maybe you need to get an authorization to do something outside the standard of care or something that is unique or unheard of, but HER2-neu biopsy is standard of care and should not require additional authorization.

And the sad part is, that patient turned out to be HER2-neu positive. She lost 4 weeks just waiting for an authorization of a test that should be a no-brainer.

We cannot even do a blood count in our office before getting authorization from some insurances. This is a very important test when we give chemotherapy, and it’s very cheap.

And then another nightmare is if you want to give a patient growth factors when you see their blood count is going down. Sometimes the insurance company will say, “When they get neutropenic fever, we’ll allow it with the next cycle.” Why do I have to wait until the patient develops such a problem to start with a treatment that could avoid it? They may end up in the hospital.

I think I’m one of the more conservative doctors; I try to do everything scientifically and only order a test or a treatment if it’s indicated. But sometimes this guidance costs more money. For example, an insurance company may say to order a CT scan first and if you don’t find your answer, then get a PET scan.

So I order a CT scan, knowing it’s not going to help, and then I tell them, “Now I need a PET scan.” That’s another week delay and an extra cost that I don’t want the system to incur.

I’ve even had some issues with lung screening scans for smokers. This screening has reduced mortality by 20%; it should be a no-brainer to encourage smokers to do it because many of them may not even need chemotherapy if you find early-stage lung cancer. And the screening is not expensive, you can do it for $90 to $100. So why do we have to get authorization for that?

Sometimes I push back and request a “peer-to-peer,” where you challenge the decision of the insurance company and speak to one of their doctors. Out of 10 doctors, maybe three or four will do the peer-to-peer. The rest will give up because it’s so frustrating.

In one case, I wanted to modify a standard regimen and give only two out of three drugs because I thought the third would be too toxic. But the insurance company wouldn’t approve the regimen because the guidelines say you have to give three drugs.

Guidelines are guidance, they should not dictate how you treat an individual patient – there should be some allowance in there for a doctor’s discretion. If not, why do we even need doctors? We could just follow treatment regimens dictated by computers. They have to allow me to personalize the care that my patient deserves and make changes so that the treatment can be tolerated.

But then, I get that one patient whom I feel I really helped and I realize, “Okay, I can help more people.”

I had this one patient, a young, 40-year-old nurse with breast cancer – also HER2-neu positive. She’d had her surgery and finished her adjuvant chemotherapy. One of the things that you do as standard of care, after a year of trastuzumab, is you start them on neratinib. There are studies that show it improves progression-free survival if you give them an extra year of this drug as an adjuvant.

I prescribed the neratinib, but the insurance company denied it because the patient “did not have positive lymph nodes and was not considered high risk.” I told them, “That’s BS, that’s not what the indication is for.” I asked for a peer-to-peer and they said the policy did not allow for peer-to-peer. So, I made a big fuss about it. We appealed, and I finally spoke to a pharmacist who worked for the insurance company. I told him, “Why did you guys deny this? It’s standard of care.” He said, “Oh, I agree with you, this will be approved. And actually, we’re going to change the policy now.”

When that pharmacist told me they were going to change the policy, it was like someone gave me 1 million dollars. Because, you know what? I didn’t just help my patient; now other patients will also get it. The hope is that if you keep fighting for something, they will change it.

I think every doctor wants to do the best for their patients. It’s not like they don’t want to, but really, I am fortunate that I have the means to do it. We’re a big practice and we have dedicated staff who can help.

If you’re a small practice, it’s almost impossible to deal with this. I have two nurse practitioners, and a lot of their work is filling out paperwork for insurance companies.

We had a colleague, a solo practitioner, who would send us his patients with complicated therapies, because he couldn’t afford the time or the effort or the risk of not getting reimbursed. His practice could have paid out $100,000 for drugs and not get a reimbursement for a few months.

Even when an insurance company does give the preauthorization, there’s always this disclaimer that it doesn’t guarantee payment. If they find in the future that your patient didn’t meet the criteria, they can still deny payment.

If the insurers refuse coverage, we really work hard at getting patients free drugs, and most of the time, we manage to do that. We either look to charitable organizations, like the Leukemia and Lymphoma Society, or we look for rare disease societies or we go to the pharmaceutical company.

For really expensive drugs, pharmaceutical companies have a program where you can enroll the patient and they can help copay or even cover the drug. For less expensive drugs, it might not be a big problem, but for a drug that can cost $18,000 to $20,000 a month, that’s a big risk to take.

It’s confusing for patients, too. They get angry and frustrated, and that’s not good for their treatment, because attitude and psychology are very important. Sometimes they yell at us because they think it’s our fault. I encourage them to call their insurance companies themselves, and some of them do.

I don’t do it with every patient, but there are some more educated patients who are advocates, and if their condition is stable, I do encourage them to call their senators or congressmen or congresswomen to complain.

I don’t mind treating complicated patients. I don’t want to say I enjoy it, but I like challenges. That’s my field, that’s medicine, that’s what I’m supposed to do. But it’s really sad and frustrating that, when you want to treat a patient, you first have to look at their insurance to see how much care you can actually give them.

Maen Hussein, MD, is physician director of finance at Florida Cancer Specialists and Research Institute, Fort Myers. He is a board member of the Florida Cancer Specialists Foundation and sits on the board of directors for the Florida Society of Clinical Oncology.

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

The correlation between stress and graying of hair has long been hypothesized, but has been difficult to prove. In addition, reversal of hair graying has been thought of as a temporary phenomenon as hair pigment goes through its natural progression of senescence.

Noel Hendrickson/Getty Images

However, the recent publication that is a collaboration between the department of psychiatry at Columbia University, New York; and the departments of dermatology at the University College Dublin, University of Miami, and the University of Manchester (England); and the Monasterium Laboratory in Münster, Germany, demonstrates a quantitative mapping of human hair graying – and its reversal – in relation to stress.

In the study, hair color of single strands of hair from seven healthy females and seven healthy males, whose mean age was 35 years (range, 9-65 years), were analyzed. In addition to hair pigment analysis, study subjects documented the stress they were experiencing each week in diaries. Using either high resolution image scanners, electron microscopy, and/or hair shaft proteomics, the investigators were able to evaluate loss of pigment within fragments small enough to have grown over one hour.

When changes in hair color were noted, variations in up to 300 proteins were documented, including an up-regulation of the fatty acid synthesis and metabolism machinery in graying. Recent studies also corroborate that fatty acid synthesis by fatty acid synthase and “transport by CPT1A ... are sufficient drivers of cell senescence, and that fatty acid metabolism regulates melanocyte aging biology” the authors wrote.

Molecularly, the investigators found that gray hairs up-regulate proteins associated with energy metabolism, mitochondria, and antioxidant defenses. The graying correlated with stress was also reversible, “at least temporarily,” based on their retrospective analysis and analysis over the 2.5-year recruitment period, the investigators wrote. Specifically, they found that graying hair “may be acutely triggered by stressful life experiences, the removal of which can trigger reversal.” From the data, they also developed a mathematical model to predict what might happen to human hair over time.

Through this study, proof-of-concept evidence is provided indicating that biobehavioral factors are linked to human hair graying dynamics. Future analysis with larger sample sizes and incorporating neuroendocrine markers may further support these correlations. This is an interesting study that elucidates the mechanisms responsible for how stress and other life exposures manifest in human biology, and, if we as human beings effectively manage that stress, how it may both reverse the negative impact and outcomes affecting our body and health.

The study was supported by the Wharton Fund and grants from the National Institutes of Health.

Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They have no relevant disclosures.

The correlation between stress and graying of hair has long been hypothesized, but has been difficult to prove. In addition, reversal of hair graying has been thought of as a temporary phenomenon as hair pigment goes through its natural progression of senescence.

Noel Hendrickson/Getty Images

However, the recent publication that is a collaboration between the department of psychiatry at Columbia University, New York; and the departments of dermatology at the University College Dublin, University of Miami, and the University of Manchester (England); and the Monasterium Laboratory in Münster, Germany, demonstrates a quantitative mapping of human hair graying – and its reversal – in relation to stress.

In the study, hair color of single strands of hair from seven healthy females and seven healthy males, whose mean age was 35 years (range, 9-65 years), were analyzed. In addition to hair pigment analysis, study subjects documented the stress they were experiencing each week in diaries. Using either high resolution image scanners, electron microscopy, and/or hair shaft proteomics, the investigators were able to evaluate loss of pigment within fragments small enough to have grown over one hour.

When changes in hair color were noted, variations in up to 300 proteins were documented, including an up-regulation of the fatty acid synthesis and metabolism machinery in graying. Recent studies also corroborate that fatty acid synthesis by fatty acid synthase and “transport by CPT1A ... are sufficient drivers of cell senescence, and that fatty acid metabolism regulates melanocyte aging biology” the authors wrote.

Molecularly, the investigators found that gray hairs up-regulate proteins associated with energy metabolism, mitochondria, and antioxidant defenses. The graying correlated with stress was also reversible, “at least temporarily,” based on their retrospective analysis and analysis over the 2.5-year recruitment period, the investigators wrote. Specifically, they found that graying hair “may be acutely triggered by stressful life experiences, the removal of which can trigger reversal.” From the data, they also developed a mathematical model to predict what might happen to human hair over time.

Through this study, proof-of-concept evidence is provided indicating that biobehavioral factors are linked to human hair graying dynamics. Future analysis with larger sample sizes and incorporating neuroendocrine markers may further support these correlations. This is an interesting study that elucidates the mechanisms responsible for how stress and other life exposures manifest in human biology, and, if we as human beings effectively manage that stress, how it may both reverse the negative impact and outcomes affecting our body and health.

The study was supported by the Wharton Fund and grants from the National Institutes of Health.

Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They have no relevant disclosures.

The correlation between stress and graying of hair has long been hypothesized, but has been difficult to prove. In addition, reversal of hair graying has been thought of as a temporary phenomenon as hair pigment goes through its natural progression of senescence.

Noel Hendrickson/Getty Images

However, the recent publication that is a collaboration between the department of psychiatry at Columbia University, New York; and the departments of dermatology at the University College Dublin, University of Miami, and the University of Manchester (England); and the Monasterium Laboratory in Münster, Germany, demonstrates a quantitative mapping of human hair graying – and its reversal – in relation to stress.

In the study, hair color of single strands of hair from seven healthy females and seven healthy males, whose mean age was 35 years (range, 9-65 years), were analyzed. In addition to hair pigment analysis, study subjects documented the stress they were experiencing each week in diaries. Using either high resolution image scanners, electron microscopy, and/or hair shaft proteomics, the investigators were able to evaluate loss of pigment within fragments small enough to have grown over one hour.

When changes in hair color were noted, variations in up to 300 proteins were documented, including an up-regulation of the fatty acid synthesis and metabolism machinery in graying. Recent studies also corroborate that fatty acid synthesis by fatty acid synthase and “transport by CPT1A ... are sufficient drivers of cell senescence, and that fatty acid metabolism regulates melanocyte aging biology” the authors wrote.

Molecularly, the investigators found that gray hairs up-regulate proteins associated with energy metabolism, mitochondria, and antioxidant defenses. The graying correlated with stress was also reversible, “at least temporarily,” based on their retrospective analysis and analysis over the 2.5-year recruitment period, the investigators wrote. Specifically, they found that graying hair “may be acutely triggered by stressful life experiences, the removal of which can trigger reversal.” From the data, they also developed a mathematical model to predict what might happen to human hair over time.

Through this study, proof-of-concept evidence is provided indicating that biobehavioral factors are linked to human hair graying dynamics. Future analysis with larger sample sizes and incorporating neuroendocrine markers may further support these correlations. This is an interesting study that elucidates the mechanisms responsible for how stress and other life exposures manifest in human biology, and, if we as human beings effectively manage that stress, how it may both reverse the negative impact and outcomes affecting our body and health.

The study was supported by the Wharton Fund and grants from the National Institutes of Health.

Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They have no relevant disclosures.

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

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

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

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

On March 16, the world was witness to a horrific act of violence when a gunman killed six Asian American women and two others at spas in the Atlanta, Georgia area. The attack prompted a national outcry and protests against the rising levels of hate and violence directed at Asian Americans and Pacific Islanders (AAPI), a community that has experienced a profound and disturbing legacy of racism in American history.

Despite this fact, my own understanding and awareness of the hate and racism experienced by the AAPI community, then and now, would be described as limited at best. Was I aware on some level? Perhaps. But if I’m being honest, I have not fully appreciated the unique experiences of AAPI colleagues, friends, and students.

That changed when I attended a White Coats Against Asian Hate & Racism rally, held by the George Washington University School of Medicine and Health Sciences 2 months after the Atlanta killings. Hearing my colleagues speak of their personal experiences, I quickly realized my lack of education on the subject of how systemic racism has long affected Asian Americans in this country.
 

Measuring the alarming rise in anti-Asian hate

The data supporting a rise in anti-Asian hate crimes have been staring us in the face for decades but have drawn increasing attention since the beginning of the COVID-19 pandemic, when these already distressingly high numbers experienced a steep rise.

Before looking at these figures, though, we must begin by defining what is considered a hate crime versus a hate incident. The National Asian Pacific American Bar Association and Asian & Pacific Islander American Health Forum have produced a beneficial summary document on precisely what separates these terms:

• A hate crime is a crime committed on the basis of the victim’s perceived or actual race, color, religion, national origin, sexual orientation, gender identity, or disability. It differs from “regular” crime in that its victims include the immediate crime target and others like them. Hate crimes affect families, communities, and, at times, an entire nation.
• A hate incident describes acts of prejudice that are not crimes and do not involve violence, threats, or property damage. The most common examples are isolated forms of speech, such as racial slurs.

Stop AAPI Hate (SAH) was founded in March 2020 as a coalition to track and analyze incidents of hate against this community. SAH’s 2020-2021 national report details 3,795 hate incidents that occurred from March 19, 2020, to Feb. 28, 2021. In a notable parallel to the Georgia killings, SAH found that Asian American women reported hate incidents 2.3 times more often than men and that businesses were the primary site of discrimination.

This rise in hate incidents has occurred in parallel with an increase in Asian American hate crimes. Recently, the Center for the Study of Hate and Extremism (CSUSB) released its Report to the Nation: Anti-Asian Prejudice & Hate Crime. CSUSB found that anti-Asian hate crimes increased by 164% in the first quarter of 2021. I re-read that data point multiple times, thinking it must be in error. If you’re asking exactly why I was having difficulty accepting this data, you have to appreciate these two critical points:

• Per the CSUSB, anti-Asian hate crimes were already surging by 146% in 2020.
• This surge occurred while overall hate crimes dropped by 7%.

So, if 2020 was a surge, the first quarter of 2021 is a hurricane. What’s perhaps most concerning is that these data only capture reported cases and therefore are a fraction of the total.

Undoubtedly, we are living through an unprecedented rise in anti-Asian hate incidents and hate crimes since the start of the pandemic. This rise in hate-related events paralleled the many pandemic-related stressors (disease, isolation, economics, mental health, etc.). Should anyone have been surprised when this most recent deadly spike of anti-Asian hate occurred in the first quarter of 2021?
 

Hate’s toll on mental health

As a psychiatrist, I’ve spent my entire career working with dedicated teams to treat patients with mental health disorders. Currently, hate is not classified by the Diagnostic and Statistical Manual of Mental Disorders as a mental illness. However, I can’t think of another emotion that is a better candidate for further research and scientific instigation, if for no other reason than to better understand when prejudice and bias transform into hatred and crime.

Surprisingly, there has been relatively little research on the topic of hate in the fields of psychology and psychiatry. I’d be willing to wager that if you asked a typical graduating class of medical students to give you an actual working definition of the emotion of hate, most would be at a loss for words.

Dr. Fischer and Dr. Halperin published a helpful article that gives a functional perspective on hate. The authors cover a great deal of research on hate and offer the following four starting points valuable in considering it:

• “Hate is different from anger because an anger target is appraised as someone whose behavior can be influenced and changed.”
• “A hate target, on the contrary, implies appraisals of the other’s malevolent nature and malicious intent.”
• “Hate is characterized by appraisals that imply a stable perception of a person or group and thus the incapability to change the extremely negative characteristics attributed to the target of hate.”
• “Everyday observations also suggest that hate is so powerful that it does, not just temporarily but permanently, destroy relations between individuals or groups.”

When I view hate with these insights in mind, it completely changes how I choose to utilize the word or concept. Hate is an emotion whose goal/action tendency is to eliminate groups (not just people or obstacles) and destroy any current or future relationships. We can take this a step further in noting that hate spreads, not only to the intended targets but potentially my “own” group. Similar to secondhand smoke, there is no risk-free exposure to hate or racism.

In the past decade, a robust body of evidence has emerged that clearly illustrates the negative health impacts of racism. Dr. Paradies and colleagues performed a systematic meta-analysis explicitly focused on racism as a determinant of health, finding that it was associated with poorer mental health, including depression, anxiety, and psychological distress. Over the past two decades, researchers have increasingly looked at the effects of racial discrimination on the AAPI community. In their 2009 review article, Dr. Gee and colleagues identified 62 empirical articles assessing the relation between discrimination and health among Asian Americans. Most of the studies found that discrimination was associated with poorer health. Of the 40 studies focused on mental health, 37 reported that discrimination was associated with poorer outcomes.

SAH recently released its very illuminating Mental Health Report. Among several key findings, two in particular caught my attention. First, Asian Americans who have experienced racism are more stressed by anti-Asian hate than the pandemic itself. Second, one in five Asian Americans who have experienced racism display racial trauma, the psychological and emotional harm caused by racism. Given the rise in hate crimes, there must be concern regarding the level of trauma being inflicted upon the Asian American community.

A complete review of the health effects of racism is beyond this article’s scope. Still, the previously mentioned studies further support the need to treat racism in general, and specifically anti-Asian hate, as the urgent public health concern that it truly is. The U.S. government recently outlined an action plan to respond to anti-Asian violence, xenophobia, and bias. These are helpful first steps, but much more is required on a societal and individual level, given the mental health disparities faced by the AAPI community.

Determining the best ways to address this urgent public health concern can be overwhelming, exhausting, and outright demoralizing. The bottom line is that if we do nothing, communities and groups will continue to suffer the effects of racial hatred. These consequences are severe and transgenerational.

But we must start somewhere. For me, that begins by gaining a better understanding of the emotion of hate and my role in either facilitating or stopping it, and by listening, listening, and listening some more to AAPI colleagues, friends, and family about their lived experience with anti-Asian hate.

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

The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.

Courtesy Dr. Cassie Feldman

With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.

It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.

The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.

According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Vicarious trauma, also used interchangeably with secondary trauma, occurs when practitioners absorb and integrate the aspects of the traumatic experience into their own consciousness. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.

So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.

Working on the front lines

Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.

Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.

This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.

They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.

Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.

Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.

“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”

Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.

Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”

Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.

The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.

“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
 

Understanding the role of psychoneuroimmunology

In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.

She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.

Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”

Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.

She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.

The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.

Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.

Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.

“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”

Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:

1. Share your own loss experience with a caring and nonjudgmental person.

2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.

3. Be willing to ask for help.

4. Be aware of risks and countertransference in our work.

5. Attend workshops.

6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.

7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.

8. Schedule play.

9. Develop a healthy self-care regimen to remain present doing this work.

10. Consider the benefits of exercise.

11. Enjoy the beauty and wonder of nature.

12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.

13. Spend time with loving family and friends.

14. Adopt a pet.

15. Eat healthy foods; get plenty of rest.

16. Walk in the rain.

17. Listen to music.

18. Enjoy a relaxing bubble bath.

19. Sing, dance, and enjoy the blessings of this life.

20. Love yourself; you truly can be your own best friend.

To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.

While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
 

Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.

Courtesy Dr. Cassie Feldman

With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.

It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.

The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.

According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Vicarious trauma, also used interchangeably with secondary trauma, occurs when practitioners absorb and integrate the aspects of the traumatic experience into their own consciousness. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.

So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.

Working on the front lines

Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.

Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.

This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.

They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.

Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.

Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.

“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”

Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.

Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”

Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.

The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.

“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
 

Understanding the role of psychoneuroimmunology

In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.

She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.

Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”

Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.

She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.

The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.

Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.

Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.

“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”

Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:

1. Share your own loss experience with a caring and nonjudgmental person.

2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.

3. Be willing to ask for help.

4. Be aware of risks and countertransference in our work.

5. Attend workshops.

6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.

7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.

8. Schedule play.

9. Develop a healthy self-care regimen to remain present doing this work.

10. Consider the benefits of exercise.

11. Enjoy the beauty and wonder of nature.

12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.

13. Spend time with loving family and friends.

14. Adopt a pet.

15. Eat healthy foods; get plenty of rest.

16. Walk in the rain.

17. Listen to music.

18. Enjoy a relaxing bubble bath.

19. Sing, dance, and enjoy the blessings of this life.

20. Love yourself; you truly can be your own best friend.

To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.

While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
 

Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

The mental health toll from the Surfside, Fla., Champlain Tower collapse will be felt by our patients for years to come. As mental health professionals in Miami-Dade County, it has been difficult to deal with the catastrophe layered on the escalating COVID-19 crisis.

Courtesy Dr. Cassie Feldman

With each passing day after the June 24 incident, we all learned who the 98 victims were. In session after session, the enormous impact of this unfathomable tragedy unfolded. Some mental health care professionals were directly affected with the loss of family members; some lost patients, and a large number of our patients lost someone or knew someone who lost someone. It was reminiscent of our work during the COVID-19 crisis when we found that we were dealing with the same stressors as those of our patients. As it was said then, we were all in the same storm – just in very different boats.

It was heartening to see how many colleagues rushed to the site of the building where family waiting areas were established. So many professionals wanted to assist that some had to be turned away.

The days right after the collapse were agonizing for all as we waited and hoped for survivors to be found. Search teams from across the United States and from Mexico and Israel – specifically, Israeli Defense Forces personnel with experience conducting operations in the wake of earthquakes in both Haiti and Nepal, took on the dangerous work. When no one was recovered after the first day, hope faded, and after 10 days, the search and rescue efforts turned to search and recovery. We were indeed a county and community in mourning.

According to Lina Haji, PsyD, GIA Miami, in addition to the direct impact of loss, clinicians who engaged in crisis response and bereavement counseling with those affected by the Surfside tragedy were subjected to vicarious trauma. Vicarious trauma, also used interchangeably with secondary trauma, occurs when practitioners absorb and integrate the aspects of the traumatic experience into their own consciousness. Mental health care providers in the Miami area not only experienced the direct effect of this tragedy but have been hearing details and harrowing stories about the unimaginable experiences their patients endured over those critical weeks. Vicarious trauma can result in our own symptoms, compassion fatigue, or burnout as clinicians. This resulted in a call for mental health providers to come to the aid of their fellow colleagues.

So, on the 1-month anniversary of the initial collapse, at the urging of Patricia Stauber, RN, LCSW, a clinician with more than 30 years’ experience in providing grief counseling in hospital and private practice settings; Antonello Bonci, MD, the founder of GIA Miami; Charlotte Tomic, director of public relations for the Institute for the Study of Global Antisemitism; and I cohosted what we hope will be several Mental Health Appreciation retreats. Our goal was to create a space to focus on healing the healers. We had hoped to hold an in-person event, but at the last moment we opted for a Zoom-based event because COVID-19 cases were rising rapidly again.

Working on the front lines

Cassie Feldman, PsyD, a licensed clinical psychologist with extensive experience working with grief, loss, end of life, and responding to trauma-related consults, reflected on her experience responding to the collapse in the earliest days – first independently at the request of community religious leaders and then as part of CADENA Foundation, a nonprofit organization dedicated to rescue, humanitarian aid, and disaster response and prevention worldwide.

Dr. Feldman worked alongside other mental health professionals, local Miami-Dade police and fire officials, and the domestic and international rescue teams (CADENA’s Go Team from Mexico and the Israeli Defense Force’s Search and Rescue Delegation), providing Psychological First Aid, crisis intervention, and disaster response to the victims’ families and survivors.

This initially was a 24-hour coverage effort, requiring Dr. Feldman and her colleagues to clear their schedules, and at times to work 18-hour shifts in the early days of the crisis to address the need for consistency and continuity. Their commitment was to show up for the victims’ families and survivors, fully embracing the chaos and the demands of the situation. She noted that the disaster brought out the best of her and her colleagues.

They divided and conquered the work, alongside clinicians from Jewish Community Services and Project Chai intervening acutely where possible, and coordinating long-term care plans for those survivors and members of the victims’ support networks in need of consistent care.

Dr. Feldman reflected on the notion that we have all been processing losses prior to this – loss of normalcy because of the pandemic, loss of people we loved as a result, other personal losses – and that this community tragedy is yet another loss to disentangle. It didn’t feel good or natural for her to passively absorb the news knowing she had both the skill set and capacity to take on an active supportive role. The first days at the community center were disorganized; it was hard to know who was who and what was what. She described parents crying out for their children and children longing for their parents. Individuals were so overcome with emotion that they grew faint. Friends and families flooded in but were unaware of how to be fully supportive. The level of trauma was so high that the only interventions that were absorbed were those that were nonverbal or that fully addressed practical needs. People were frightened and in a state of shock.

Day by day, more order ensued and the efforts became more coordinated, but it became apparent to her that the “family reunification center” was devoid of reunification. She and her colleagues’ primary role became aiding the police department in making death notifications to the families and being supportive of the victims’ families and their loved ones during and in between the formal briefings, where so many concerned family members and friends gathered and waited.

“As the days went on, things became more structured and predictable,” Dr. Feldman noted. “We continued to connect with the victims’ families and survivors, [listened to] their stories, shared meals with them, spent downtime with them, began to intimately know their loved ones, and all the barriers they were now facing. We became invested in them, their unique intricacies, and to care deeply for them like our own families and loved ones. Small talk and conversation morphed into silent embraces where spoken words weren’t necessary.”

Dr. Feldman said some of her earliest memories were visiting ICU patients alongside her father, a critical care and ICU physician. Her father taught her that nonverbal communication and connection can be offered to patients in the most poignant moments of suffering.

Her “nascent experiences in the ICU,” she said, taught her that “the most useful of interventions was just being with people in their pain and bearing witness at times when there were just no words.”

Dr. Feldman said that when many of her colleagues learned about the switch from rescue to recovery, the pull was to jump in their cars and drive to the hotel where the families were based to offer support.

The unity she witnessed – from the disparate clinicians who were virtual strangers before the incident but a team afterward, from the families and the community, and from the first responders and rescue teams – was inspiring, Dr. Feldman said.

“We were all forced to think beyond ourselves, push ourselves past our limits, and unify in a way that remedied this period in history of deep fragmentation,” she said.
 

Understanding the role of psychoneuroimmunology

In another presentation during the Zoom event, Ms. Stauber offered her insights about the importance of support among mental health clinicians.

She cited research on women with HIV showing that those who are part of a support group had a stronger immune response than those who were not.

Ms. Stauber said the impact of COVID-19 and its ramifications – including fear, grief over losing loved ones, isolation from friends and family, and interference/cessation of normal routines – has put an enormous strain on clinicians and clients. One of her clients had to take her mother to the emergency room – never to see her again. She continues to ask: “If I’d been there, could I have saved her?”

Another client whose husband died of COVID-19–related illness agonizes over not being able to be at her husband’s side, not being able to hold his hand, not being able to say goodbye.

She said other cultures are more accepting of suffering as a condition of life and the acknowledgment that our time on earth is limited.

The “quick fix for everything” society carries over to people’s grief, said Ms. Stauber. As a result, many find it difficult to appreciate how much time it takes to heal.

Normal uncomplicated grief can take approximately 2-3 years, she said. By then, the shock has been wearing off, the emotional roller coaster of loss is calming down, coping skills are strengthened, and life can once again be more fulfilling or meaningful. Complicated grief or grief with trauma takes much longer, said Ms. Stauber, who is a consultant with a national crisis and debriefing company providing trauma and bereavement support to Fortune 500 companies.

Trauma adds another complexity to loss. To begin to appreciate the rough road ahead, Ms. Stauber said, it is important to understand the basic challenges facing grieving people.

“This is where our profession may be needed; we are providing support for those suffering the immense pain of loss in a world that often has difficulty being present or patient with loss,” she said. “We are indeed providing an emotional life raft.”

Ultimately, self-care is critical, Ms. Stauber said. “Consider self-care a job requirement” to be successful. She also offered the following tips for self-care:

1. Share your own loss experience with a caring and nonjudgmental person.

2. Consider ongoing supervision and consultation with colleagues who understand the nature of your work.

3. Be willing to ask for help.

4. Be aware of risks and countertransference in our work.

5. Attend workshops.

6. Remember that you do not have to and cannot do it all by yourself – we absolutely need more grief and trauma trained therapists.

7. Involve yourself in activities outside of work that feed your soul and nourish your spirit.

8. Schedule play.

9. Develop a healthy self-care regimen to remain present doing this work.

10. Consider the benefits of exercise.

11. Enjoy the beauty and wonder of nature.

12. Consider yoga, meditation, spa retreats – such as Kripalu, Miraval, and Canyon Ranch.

13. Spend time with loving family and friends.

14. Adopt a pet.

15. Eat healthy foods; get plenty of rest.

16. Walk in the rain.

17. Listen to music.

18. Enjoy a relaxing bubble bath.

19. Sing, dance, and enjoy the blessings of this life.

20. Love yourself; you truly can be your own best friend.

To advocate on behalf of mental health for patients, we must do the same for mental health professionals. The retreat was well received, and we learned a lot from our speakers. After the program, we offered a 45-minute yoga class and then 30-minute sound bowl meditation. We plan to repeat the event in September to help our community deal with the ongoing stress of such overwhelming loss.

While our community will never be the same, we hope that, by coming together, we can all find a way to support one another and strive to help ourselves and others manage as we navigate yet another unprecedented crisis.
 

Dr. Ritvo, who has more than 30 years’ experience in psychiatry, practices telemedicine. She is author of “BeKindr – The Transformative Power of Kindness” (Hellertown, Pa.: Momosa Publishing, 2018). Dr. Ritvo has no disclosures.

Among the pressures felt by hospitalists are concerns about being subject to a malpractice claim. Anxiety about malpractice influences the way hospitalists practice, giving rise to defensive medicine.

One survey, which asked hospitalists to retrospectively rate which of their orders represented defensive medicine, found that 28% of orders were deemed defensive.¹ Defensive medicine can lead to low-value medical care, drive up health care costs, and potentially subject patients to unnecessary testing.^2,3

Encouragingly, medical malpractice claims rates have, overall, been downtrending. An analysis of data from the National Practitioner Data Bank, which is a repository of all paid malpractice claims against individual physicians, found that malpractice claims rates decreased by 55.7% from 1992 to 2014 among all specialties, and by 46.1% for internal medicine physicians.⁴ The data used in this analysis did not separate hospitalists from other internal medicine physicians. An older study of malpractice claims against hospitalists found that hospitalists had significantly lower claims rates than non-hospitalist internal medicine physicians.⁵

Current malpractice environment for hospitalists

Seeking to shed light on the current malpractice environment faced by hospitalists, a recent study examined claims against hospitalists using the Comparative Benchmarking System (CBS), a national database of malpractice claims containing approximately 30% of all U.S. malpractice claims, which is maintained by CRICO, the malpractice insurer for the Harvard-affiliated medical institutions.⁶

Claims in the CBS database are examined by trained nurse coders who review the claims, along with the associated medical and legal records, to understand the contributing factors behind the adverse event leading to the claim.

Contrary to the trends for nearly all other physician specialties, the malpractice claims rates of hospitalists were not downtrending, going from 1.77 claims per 100 physician-years from 2009-2013 to 2.08 claims per 100 physician-years from 2014-2018. The overall claims rate for hospitalists was significantly higher than that for internal medicine subspecialists (though roughly the same as the claims rate for non-hospitalist general internal medicine physicians). These sobering findings raise the important question of why hospitalists claims rates are heading in the wrong direction.

One possible answer relates the ever-broadening scope of hospitalist practice. Hospitalists are being asked to care for surgical patients and other patient populations that they may have less familiarity with, increasing the risk of medical errors. Among the other specialties most commonly also named in hospitalist claims, general surgery and orthopedic surgery are in the top five. The extraordinary growth in the field of hospital medicine has meant a need to hire an increasing number of hospitalists, leading to less-experienced physicians entering the field.
 

Making hospital medicine safer

A more urgent question than what is driving the trends in hospitalist claims rates is what can be done to avoid adverse events and make hospital medicine safer. One potential answer is thoughtful collaboration arrangements with the surgical and other specialties with whom hospitalists may be co-managing patients.

Questions about who responds to what types of clinical issues that might arise and specific domains of responsibility should be defined in advance, so that a lack of role clarity does not negatively impact patient care. Given that hospitalists will be less comfortable addressing more technical surgical issues, expectations about surgeons’ availability should be established. Nocturnists may be tasked with overnight cross-coverage of patients on services, such as oncology and cardiology, that subspecialty physicians have responsibility for during the day. Agreeing upon triggers for when the nocturnist should contact the daytime subspecialty attending (for example, if a rapid response is called on their patient) should be considered, so that nocturnists are not left deciding, in the moment, whether to call the daytime attending. Measures such as this ensure that everyone’s expectations are aligned. In addition, new hospitalists need to be offered support, in the form of training and mentorship.

CBS malpractice data, which includes the contributing factors underlying what went wrong, illuminates potential targets for programs designed to enhance patient safety. In the recent hospitalist malpractice study, the two contributing factors that were the best predictors of a hospitalist malpractice claim closing with payment to the claimant were clinical judgment errors and communication breakdowns. Identifying measures that are effective in promoting patient safety by refining the clinical judgement of clinicians is a challenge, and there are limited data demonstrating what programs are effective in this area.

Clinical decision support (CDS) systems have shown promise in promoting guideline-concordant care.⁷ However, the role of CDS in aiding the higher-stakes clinical decisions that may be called into question after an adverse outcome is not well defined. Alerts that a patient may be developing sepsis is one type of CDS that has been extensively studied and has been shown to be of some benefit.⁸ The importance of clinical judgment to whether payment is made on a malpractice claim can inform risk management strategies. Hospitalists should document the thought process behind their decision making in the chart, especially for important clinical decisions. A note showing that the clinician was thoughtfully weighing the risks and benefits using the data available at the time will help make a case defensible if an adverse outcome occurs.

The effect of communication breakdowns on hospitalist case outcomes highlights the importance of measures to improve and systematize communication among clinicians, particularly at vulnerable junctures – such as handoffs from the day team to the night team, and transitions from one care setting to another. An example of an intervention to improve handoffs with cogent evidence to support it is I-PASS, which is an approach to handoffs between teams in which information about the patient’s illness severity, clinical background, and contingencies is conveyed and synthesized in a structured manner. A study of the effect of implementation of I-PASS among nine pediatric residency programs demonstrated a 30% reduction in preventable adverse events.⁹

Applying insights from malpractice claims analysis to clinical practice

The systematic review of malpractice cases to determine the contributing factors and other case attributes is an important source of patient safety insights. The process breakdowns described by the contributing factors can inform the design of patient safety initiatives. In addition, malpractice data provides information on which specialties and what types of clinicians are being named together in malpractice claims.

In the hospitalist malpractice study, in addition to general surgery and orthopedic surgery, the other clinical services most commonly subject to claims along with hospitalists were nursing, emergency medicine, and cardiology. Another observation was that physician assistants and nurse practitioners are increasingly being named in hospitalist claims. This information is crucial to guiding who needs to be in the room with hospitalists when efforts are undertaken to enhance patient safety within hospital medicine.

An understandable response to the finding that hospitalist claims rates are not decreasing is for hospitalists to seek ways to lower their risk of being named in a malpractice claim. Of course, avoiding adverse events by providing the safest possible care is paramount. Even when patients do suffer adverse events due to a physician negligence, only rarely, less than 5% of the time, does this result in a malpractice claim.¹⁰ Important lessons in risk management can be learned from examining why patients decide to sue when mistakes lead to bad outcomes.

An analysis of plaintiffs’ depositions found that the key reasons that patients decided to file a malpractice claim include a poor relationship with the physician – specifically, a lack of empathy from the physician, feeling deserted by the physician, and feeling devalued by the physician.¹¹ These findings support the use of programs that assist physicians in compassionately disclosing adverse events to patients. Among inpatient physicians, patient satisfaction survey questions about the time the physician spent with the patient and the physician’s concern for the patient are better predictors of the physicians’ risk management performance than is the question about the skill of the physician.¹² In the aftermath of an adverse event, focusing on maintaining a strong patient-physician relationship is not only the right the thing to do, the data tell us that it is also a sensible approach to reducing medicolegal risk.
 

Dr. Schaffer practices as a member of the Hospital Medicine Unit at Brigham and Women’s Hospital, Boston, where he serves as an attending physician on the inpatient general medicine services. An instructor at Harvard Medical School, his academic interests include research using large medical malpractice databases to examine temporal trends in medical malpractice.

References

1. Rothberg MB, et al. The cost of defensive medicine on 3 hospital medicine services. JAMA Intern Med. 2014;174(11):1867-1868. doi:10.1001/jamainternmed.2014.4649.

2. Kachalia A, et al. Overuse of testing in preoperative evaluation and syncope: A survey of hospitalists. Ann Intern Med. 2015;162(2):100-108. doi: 10.7326/M14-0694.

3. Mello MM, et al. National costs of the medical liability system. Health Aff (Millwood). 2010;29(9):1569-1577. doi: 10.1377/hlthaff.2009.0807.

4. Schaffer AC, et al. Rates and characteristics of paid malpractice claims among U.S. physicians by specialty, 1992-2014. JAMA Intern Med. 2017;177(5):710-718. doi:10.1001/jamainternmed.2017.0311.

5. Schaffer AC, et al. Liability impact of the hospitalist model of care. J Hosp Med. 2014;9(12):750-755. doi: 10.1002/jhm.2244.

6. Schaffer AC, et al. Rates and characteristics of medical malpractice claims against hospitalists. J Hosp Med. 2021 Jul;16(7):390-396. doi: 10.12788/jhm.3557.

7. Poon EG. Clinical decision support: a tool of the hospital trade. J Hosp Med. 2015;10(1):60-61. doi: 10.1002/jhm.2295.

8. Makam AN, Nguyen OK, Auerbach AD. Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review. J Hosp Med. 2015;10(6):396-402. doi: 10.1002/jhm.2347.

9. Starmer AJ, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812. doi: 10.1056/NEJMsa1405556.

10. Localio AR, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991;325(4):245-251. doi: 10.1056/NEJM199107253250405.

11. Beckman HB, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365-1370. doi:10.1001/archinte.1994.00420120093010.

12. Stelfox HT, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133. doi: 10.1016/j.amjmed.2005.01.060.

Among the pressures felt by hospitalists are concerns about being subject to a malpractice claim. Anxiety about malpractice influences the way hospitalists practice, giving rise to defensive medicine.

One survey, which asked hospitalists to retrospectively rate which of their orders represented defensive medicine, found that 28% of orders were deemed defensive.¹ Defensive medicine can lead to low-value medical care, drive up health care costs, and potentially subject patients to unnecessary testing.^2,3

Encouragingly, medical malpractice claims rates have, overall, been downtrending. An analysis of data from the National Practitioner Data Bank, which is a repository of all paid malpractice claims against individual physicians, found that malpractice claims rates decreased by 55.7% from 1992 to 2014 among all specialties, and by 46.1% for internal medicine physicians.⁴ The data used in this analysis did not separate hospitalists from other internal medicine physicians. An older study of malpractice claims against hospitalists found that hospitalists had significantly lower claims rates than non-hospitalist internal medicine physicians.⁵

Current malpractice environment for hospitalists

Seeking to shed light on the current malpractice environment faced by hospitalists, a recent study examined claims against hospitalists using the Comparative Benchmarking System (CBS), a national database of malpractice claims containing approximately 30% of all U.S. malpractice claims, which is maintained by CRICO, the malpractice insurer for the Harvard-affiliated medical institutions.⁶

Claims in the CBS database are examined by trained nurse coders who review the claims, along with the associated medical and legal records, to understand the contributing factors behind the adverse event leading to the claim.

Contrary to the trends for nearly all other physician specialties, the malpractice claims rates of hospitalists were not downtrending, going from 1.77 claims per 100 physician-years from 2009-2013 to 2.08 claims per 100 physician-years from 2014-2018. The overall claims rate for hospitalists was significantly higher than that for internal medicine subspecialists (though roughly the same as the claims rate for non-hospitalist general internal medicine physicians). These sobering findings raise the important question of why hospitalists claims rates are heading in the wrong direction.

One possible answer relates the ever-broadening scope of hospitalist practice. Hospitalists are being asked to care for surgical patients and other patient populations that they may have less familiarity with, increasing the risk of medical errors. Among the other specialties most commonly also named in hospitalist claims, general surgery and orthopedic surgery are in the top five. The extraordinary growth in the field of hospital medicine has meant a need to hire an increasing number of hospitalists, leading to less-experienced physicians entering the field.
 

Making hospital medicine safer

A more urgent question than what is driving the trends in hospitalist claims rates is what can be done to avoid adverse events and make hospital medicine safer. One potential answer is thoughtful collaboration arrangements with the surgical and other specialties with whom hospitalists may be co-managing patients.

Questions about who responds to what types of clinical issues that might arise and specific domains of responsibility should be defined in advance, so that a lack of role clarity does not negatively impact patient care. Given that hospitalists will be less comfortable addressing more technical surgical issues, expectations about surgeons’ availability should be established. Nocturnists may be tasked with overnight cross-coverage of patients on services, such as oncology and cardiology, that subspecialty physicians have responsibility for during the day. Agreeing upon triggers for when the nocturnist should contact the daytime subspecialty attending (for example, if a rapid response is called on their patient) should be considered, so that nocturnists are not left deciding, in the moment, whether to call the daytime attending. Measures such as this ensure that everyone’s expectations are aligned. In addition, new hospitalists need to be offered support, in the form of training and mentorship.

CBS malpractice data, which includes the contributing factors underlying what went wrong, illuminates potential targets for programs designed to enhance patient safety. In the recent hospitalist malpractice study, the two contributing factors that were the best predictors of a hospitalist malpractice claim closing with payment to the claimant were clinical judgment errors and communication breakdowns. Identifying measures that are effective in promoting patient safety by refining the clinical judgement of clinicians is a challenge, and there are limited data demonstrating what programs are effective in this area.

Clinical decision support (CDS) systems have shown promise in promoting guideline-concordant care.⁷ However, the role of CDS in aiding the higher-stakes clinical decisions that may be called into question after an adverse outcome is not well defined. Alerts that a patient may be developing sepsis is one type of CDS that has been extensively studied and has been shown to be of some benefit.⁸ The importance of clinical judgment to whether payment is made on a malpractice claim can inform risk management strategies. Hospitalists should document the thought process behind their decision making in the chart, especially for important clinical decisions. A note showing that the clinician was thoughtfully weighing the risks and benefits using the data available at the time will help make a case defensible if an adverse outcome occurs.

The effect of communication breakdowns on hospitalist case outcomes highlights the importance of measures to improve and systematize communication among clinicians, particularly at vulnerable junctures – such as handoffs from the day team to the night team, and transitions from one care setting to another. An example of an intervention to improve handoffs with cogent evidence to support it is I-PASS, which is an approach to handoffs between teams in which information about the patient’s illness severity, clinical background, and contingencies is conveyed and synthesized in a structured manner. A study of the effect of implementation of I-PASS among nine pediatric residency programs demonstrated a 30% reduction in preventable adverse events.⁹

Applying insights from malpractice claims analysis to clinical practice

The systematic review of malpractice cases to determine the contributing factors and other case attributes is an important source of patient safety insights. The process breakdowns described by the contributing factors can inform the design of patient safety initiatives. In addition, malpractice data provides information on which specialties and what types of clinicians are being named together in malpractice claims.

In the hospitalist malpractice study, in addition to general surgery and orthopedic surgery, the other clinical services most commonly subject to claims along with hospitalists were nursing, emergency medicine, and cardiology. Another observation was that physician assistants and nurse practitioners are increasingly being named in hospitalist claims. This information is crucial to guiding who needs to be in the room with hospitalists when efforts are undertaken to enhance patient safety within hospital medicine.

An understandable response to the finding that hospitalist claims rates are not decreasing is for hospitalists to seek ways to lower their risk of being named in a malpractice claim. Of course, avoiding adverse events by providing the safest possible care is paramount. Even when patients do suffer adverse events due to a physician negligence, only rarely, less than 5% of the time, does this result in a malpractice claim.¹⁰ Important lessons in risk management can be learned from examining why patients decide to sue when mistakes lead to bad outcomes.

An analysis of plaintiffs’ depositions found that the key reasons that patients decided to file a malpractice claim include a poor relationship with the physician – specifically, a lack of empathy from the physician, feeling deserted by the physician, and feeling devalued by the physician.¹¹ These findings support the use of programs that assist physicians in compassionately disclosing adverse events to patients. Among inpatient physicians, patient satisfaction survey questions about the time the physician spent with the patient and the physician’s concern for the patient are better predictors of the physicians’ risk management performance than is the question about the skill of the physician.¹² In the aftermath of an adverse event, focusing on maintaining a strong patient-physician relationship is not only the right the thing to do, the data tell us that it is also a sensible approach to reducing medicolegal risk.
 

Dr. Schaffer practices as a member of the Hospital Medicine Unit at Brigham and Women’s Hospital, Boston, where he serves as an attending physician on the inpatient general medicine services. An instructor at Harvard Medical School, his academic interests include research using large medical malpractice databases to examine temporal trends in medical malpractice.

References

1. Rothberg MB, et al. The cost of defensive medicine on 3 hospital medicine services. JAMA Intern Med. 2014;174(11):1867-1868. doi:10.1001/jamainternmed.2014.4649.

2. Kachalia A, et al. Overuse of testing in preoperative evaluation and syncope: A survey of hospitalists. Ann Intern Med. 2015;162(2):100-108. doi: 10.7326/M14-0694.

3. Mello MM, et al. National costs of the medical liability system. Health Aff (Millwood). 2010;29(9):1569-1577. doi: 10.1377/hlthaff.2009.0807.

4. Schaffer AC, et al. Rates and characteristics of paid malpractice claims among U.S. physicians by specialty, 1992-2014. JAMA Intern Med. 2017;177(5):710-718. doi:10.1001/jamainternmed.2017.0311.

5. Schaffer AC, et al. Liability impact of the hospitalist model of care. J Hosp Med. 2014;9(12):750-755. doi: 10.1002/jhm.2244.

6. Schaffer AC, et al. Rates and characteristics of medical malpractice claims against hospitalists. J Hosp Med. 2021 Jul;16(7):390-396. doi: 10.12788/jhm.3557.

7. Poon EG. Clinical decision support: a tool of the hospital trade. J Hosp Med. 2015;10(1):60-61. doi: 10.1002/jhm.2295.

8. Makam AN, Nguyen OK, Auerbach AD. Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review. J Hosp Med. 2015;10(6):396-402. doi: 10.1002/jhm.2347.

9. Starmer AJ, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812. doi: 10.1056/NEJMsa1405556.

10. Localio AR, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991;325(4):245-251. doi: 10.1056/NEJM199107253250405.

11. Beckman HB, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365-1370. doi:10.1001/archinte.1994.00420120093010.

12. Stelfox HT, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133. doi: 10.1016/j.amjmed.2005.01.060.

Among the pressures felt by hospitalists are concerns about being subject to a malpractice claim. Anxiety about malpractice influences the way hospitalists practice, giving rise to defensive medicine.

One survey, which asked hospitalists to retrospectively rate which of their orders represented defensive medicine, found that 28% of orders were deemed defensive.¹ Defensive medicine can lead to low-value medical care, drive up health care costs, and potentially subject patients to unnecessary testing.^2,3

Encouragingly, medical malpractice claims rates have, overall, been downtrending. An analysis of data from the National Practitioner Data Bank, which is a repository of all paid malpractice claims against individual physicians, found that malpractice claims rates decreased by 55.7% from 1992 to 2014 among all specialties, and by 46.1% for internal medicine physicians.⁴ The data used in this analysis did not separate hospitalists from other internal medicine physicians. An older study of malpractice claims against hospitalists found that hospitalists had significantly lower claims rates than non-hospitalist internal medicine physicians.⁵

Current malpractice environment for hospitalists

Seeking to shed light on the current malpractice environment faced by hospitalists, a recent study examined claims against hospitalists using the Comparative Benchmarking System (CBS), a national database of malpractice claims containing approximately 30% of all U.S. malpractice claims, which is maintained by CRICO, the malpractice insurer for the Harvard-affiliated medical institutions.⁶

Claims in the CBS database are examined by trained nurse coders who review the claims, along with the associated medical and legal records, to understand the contributing factors behind the adverse event leading to the claim.

Contrary to the trends for nearly all other physician specialties, the malpractice claims rates of hospitalists were not downtrending, going from 1.77 claims per 100 physician-years from 2009-2013 to 2.08 claims per 100 physician-years from 2014-2018. The overall claims rate for hospitalists was significantly higher than that for internal medicine subspecialists (though roughly the same as the claims rate for non-hospitalist general internal medicine physicians). These sobering findings raise the important question of why hospitalists claims rates are heading in the wrong direction.

One possible answer relates the ever-broadening scope of hospitalist practice. Hospitalists are being asked to care for surgical patients and other patient populations that they may have less familiarity with, increasing the risk of medical errors. Among the other specialties most commonly also named in hospitalist claims, general surgery and orthopedic surgery are in the top five. The extraordinary growth in the field of hospital medicine has meant a need to hire an increasing number of hospitalists, leading to less-experienced physicians entering the field.
 

Making hospital medicine safer

A more urgent question than what is driving the trends in hospitalist claims rates is what can be done to avoid adverse events and make hospital medicine safer. One potential answer is thoughtful collaboration arrangements with the surgical and other specialties with whom hospitalists may be co-managing patients.

Questions about who responds to what types of clinical issues that might arise and specific domains of responsibility should be defined in advance, so that a lack of role clarity does not negatively impact patient care. Given that hospitalists will be less comfortable addressing more technical surgical issues, expectations about surgeons’ availability should be established. Nocturnists may be tasked with overnight cross-coverage of patients on services, such as oncology and cardiology, that subspecialty physicians have responsibility for during the day. Agreeing upon triggers for when the nocturnist should contact the daytime subspecialty attending (for example, if a rapid response is called on their patient) should be considered, so that nocturnists are not left deciding, in the moment, whether to call the daytime attending. Measures such as this ensure that everyone’s expectations are aligned. In addition, new hospitalists need to be offered support, in the form of training and mentorship.

CBS malpractice data, which includes the contributing factors underlying what went wrong, illuminates potential targets for programs designed to enhance patient safety. In the recent hospitalist malpractice study, the two contributing factors that were the best predictors of a hospitalist malpractice claim closing with payment to the claimant were clinical judgment errors and communication breakdowns. Identifying measures that are effective in promoting patient safety by refining the clinical judgement of clinicians is a challenge, and there are limited data demonstrating what programs are effective in this area.

Clinical decision support (CDS) systems have shown promise in promoting guideline-concordant care.⁷ However, the role of CDS in aiding the higher-stakes clinical decisions that may be called into question after an adverse outcome is not well defined. Alerts that a patient may be developing sepsis is one type of CDS that has been extensively studied and has been shown to be of some benefit.⁸ The importance of clinical judgment to whether payment is made on a malpractice claim can inform risk management strategies. Hospitalists should document the thought process behind their decision making in the chart, especially for important clinical decisions. A note showing that the clinician was thoughtfully weighing the risks and benefits using the data available at the time will help make a case defensible if an adverse outcome occurs.

The effect of communication breakdowns on hospitalist case outcomes highlights the importance of measures to improve and systematize communication among clinicians, particularly at vulnerable junctures – such as handoffs from the day team to the night team, and transitions from one care setting to another. An example of an intervention to improve handoffs with cogent evidence to support it is I-PASS, which is an approach to handoffs between teams in which information about the patient’s illness severity, clinical background, and contingencies is conveyed and synthesized in a structured manner. A study of the effect of implementation of I-PASS among nine pediatric residency programs demonstrated a 30% reduction in preventable adverse events.⁹

Applying insights from malpractice claims analysis to clinical practice

The systematic review of malpractice cases to determine the contributing factors and other case attributes is an important source of patient safety insights. The process breakdowns described by the contributing factors can inform the design of patient safety initiatives. In addition, malpractice data provides information on which specialties and what types of clinicians are being named together in malpractice claims.

In the hospitalist malpractice study, in addition to general surgery and orthopedic surgery, the other clinical services most commonly subject to claims along with hospitalists were nursing, emergency medicine, and cardiology. Another observation was that physician assistants and nurse practitioners are increasingly being named in hospitalist claims. This information is crucial to guiding who needs to be in the room with hospitalists when efforts are undertaken to enhance patient safety within hospital medicine.

An understandable response to the finding that hospitalist claims rates are not decreasing is for hospitalists to seek ways to lower their risk of being named in a malpractice claim. Of course, avoiding adverse events by providing the safest possible care is paramount. Even when patients do suffer adverse events due to a physician negligence, only rarely, less than 5% of the time, does this result in a malpractice claim.¹⁰ Important lessons in risk management can be learned from examining why patients decide to sue when mistakes lead to bad outcomes.

An analysis of plaintiffs’ depositions found that the key reasons that patients decided to file a malpractice claim include a poor relationship with the physician – specifically, a lack of empathy from the physician, feeling deserted by the physician, and feeling devalued by the physician.¹¹ These findings support the use of programs that assist physicians in compassionately disclosing adverse events to patients. Among inpatient physicians, patient satisfaction survey questions about the time the physician spent with the patient and the physician’s concern for the patient are better predictors of the physicians’ risk management performance than is the question about the skill of the physician.¹² In the aftermath of an adverse event, focusing on maintaining a strong patient-physician relationship is not only the right the thing to do, the data tell us that it is also a sensible approach to reducing medicolegal risk.
 

Dr. Schaffer practices as a member of the Hospital Medicine Unit at Brigham and Women’s Hospital, Boston, where he serves as an attending physician on the inpatient general medicine services. An instructor at Harvard Medical School, his academic interests include research using large medical malpractice databases to examine temporal trends in medical malpractice.

References

1. Rothberg MB, et al. The cost of defensive medicine on 3 hospital medicine services. JAMA Intern Med. 2014;174(11):1867-1868. doi:10.1001/jamainternmed.2014.4649.

2. Kachalia A, et al. Overuse of testing in preoperative evaluation and syncope: A survey of hospitalists. Ann Intern Med. 2015;162(2):100-108. doi: 10.7326/M14-0694.

3. Mello MM, et al. National costs of the medical liability system. Health Aff (Millwood). 2010;29(9):1569-1577. doi: 10.1377/hlthaff.2009.0807.

4. Schaffer AC, et al. Rates and characteristics of paid malpractice claims among U.S. physicians by specialty, 1992-2014. JAMA Intern Med. 2017;177(5):710-718. doi:10.1001/jamainternmed.2017.0311.

5. Schaffer AC, et al. Liability impact of the hospitalist model of care. J Hosp Med. 2014;9(12):750-755. doi: 10.1002/jhm.2244.

6. Schaffer AC, et al. Rates and characteristics of medical malpractice claims against hospitalists. J Hosp Med. 2021 Jul;16(7):390-396. doi: 10.12788/jhm.3557.

7. Poon EG. Clinical decision support: a tool of the hospital trade. J Hosp Med. 2015;10(1):60-61. doi: 10.1002/jhm.2295.

8. Makam AN, Nguyen OK, Auerbach AD. Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review. J Hosp Med. 2015;10(6):396-402. doi: 10.1002/jhm.2347.

9. Starmer AJ, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812. doi: 10.1056/NEJMsa1405556.

10. Localio AR, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991;325(4):245-251. doi: 10.1056/NEJM199107253250405.

11. Beckman HB, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154(12):1365-1370. doi:10.1001/archinte.1994.00420120093010.

12. Stelfox HT, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005;118(10):1126-1133. doi: 10.1016/j.amjmed.2005.01.060.

I have been a proud hospitalist for more than 20 years, and yet I have never been prouder to be a hospitalist than now. The pandemic has been brutal, killing more than 600,000 Americans as of this writing. It has stretched the health care system, its doctors, nurses, and other providers to the limit. Yet we will get through it, we are getting through it, and hospitalists deserve a huge portion of the credit.

According to the CDC, there have been over 2.3 million COVID-19 hospitalizations. In my home state of Maryland, between two-thirds and three-quarters of hospitalized COVID patients are cared for on general medical floors, the domain of hospitalists. When hospitals needed COVID units, hospitalists stepped up to design and staff them. When our ICU colleagues needed support, especially in those early dark days, hospitalists stepped in. When our outpatient colleagues were called into the hospital, hospitalists were there to help them on board. When the House of Medicine was in chaos due to COVID-19, hospitalists ran towards that fire. Our previous 20+ years of collective experience made us the ideal specialty to manage the inpatient challenges over the last 18 months.

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

Need a new way to teach residents and students on the wards? Check.

Need a whole new unit – no, wait – a new hospital wing? No, scratch that – a whole new COVID hospital in a few weeks? Check. (I personally did that last one at the Baltimore Convention Center!)

For me and many hospitalists like me, it is as if the last 20 years were prep work for the pandemic.

Here at SHM, we know the pandemic is hard work – exhausting, even. SHM has been actively focused on supporting hospitalists during this crisis so that hospitalists can focus on patients. Early in the pandemic, SHM quickly pivoted to supply hospitalists with COVID-19 resources in their fight against the coronavirus. Numerous COVID-19 webinars, a COVID addendum to the State of Hospital Medicine Report, and a dedicated COVID issue of the Journal of Hospital Medicine were early and successful information dissemination strategies.

As the world – and hospitalists – dug in for a multi-year pandemic, SHM continued to advance the care of patients by opening our library of educational content for free to anyone. Our Public Policy Committee was active around both COVID-19- and hospitalist-related topics: immigration, telehealth, wellbeing, and financial impacts, to name a few.

As the pandemic slogged on, our Wellbeing Task Force came up with innovative support measures, including a check-in guide for hospitalists and fellow health care workers and dedicated wellness sessions complete with a licensed therapist for members. All the while, despite the restrictions and hurdles the pandemic has thrown our way, SHM members keep meeting and collaborating through virtual chapter events, committee work, special interest groups, and our annual conference, SHM Converge. Thank you to the countless members who donated their time to SHM, so that SHM could support hospitalists and their patients.

Now, we are transitioning into a new phase of the pandemic. The medical miracles that are the COVID-19 vaccines have made that possible. Fully vaccinated, I no longer worry that every time someone sneezes, or when I care for patients with a fever, that I am playing a high stakes poker game with my life. Don’t get me wrong; as I write, the Delta variant has a hold on the nation, and I know it’s not over yet. But it does appear as if the medical war on COVID is shifting from national to regional (or even local) responses.

During this new phase, we must rebuild our personal and professional lives. If you haven’t read Retired Lieutenant General Mark Hertling’s perspective piece in the August issue of the Journal of Hospital Medicine, I strongly encourage you to do so. He shares profound lessons on transitioning from active combat that are directly applicable to hospitalists who have been “deployed” battling COVID-19.

SHM will continue to pivot to meet our members’ needs too. We are already gearing up for more in-person education and networking. Chapters are starting to meet in person, and SHM is happy to provide visiting faculty. I will visit members from Florida to Maine and places in between starting this fall! Our Board of Directors and other SHM leaders are also starting to meet with members in person. Our own Leadership Academy will take place at Amelia Island in Florida in October, where we can learn, network, and even decompress. We also can’t wait for SHM Converge 2022 in Nashville, where we hope to reunite with many of you after 2 years of virtual conferences.

Our response to the pandemic, a once in a century crisis where our own safety was at risk, where doing the right thing might mean death or harming loved ones, our response of running into the fire to save lives is truly inspiring. The power of care – for our patients, for our family and friends, and for our hospital medicine community and the community at large – is evident more now than ever.

There have always been good reasons to be proud of being a hospitalist: taking care of the acutely ill, helping hospitals improve, teaching young doctors, and watching my specialty grow by leaps and bounds, to name just a few. But I’ve never been prouder than I am now.

Dr. Howell is the CEO of the Society of Hospital Medicine.

I have been a proud hospitalist for more than 20 years, and yet I have never been prouder to be a hospitalist than now. The pandemic has been brutal, killing more than 600,000 Americans as of this writing. It has stretched the health care system, its doctors, nurses, and other providers to the limit. Yet we will get through it, we are getting through it, and hospitalists deserve a huge portion of the credit.

According to the CDC, there have been over 2.3 million COVID-19 hospitalizations. In my home state of Maryland, between two-thirds and three-quarters of hospitalized COVID patients are cared for on general medical floors, the domain of hospitalists. When hospitals needed COVID units, hospitalists stepped up to design and staff them. When our ICU colleagues needed support, especially in those early dark days, hospitalists stepped in. When our outpatient colleagues were called into the hospital, hospitalists were there to help them on board. When the House of Medicine was in chaos due to COVID-19, hospitalists ran towards that fire. Our previous 20+ years of collective experience made us the ideal specialty to manage the inpatient challenges over the last 18 months.

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

Need a new way to teach residents and students on the wards? Check.

Need a whole new unit – no, wait – a new hospital wing? No, scratch that – a whole new COVID hospital in a few weeks? Check. (I personally did that last one at the Baltimore Convention Center!)

For me and many hospitalists like me, it is as if the last 20 years were prep work for the pandemic.

Here at SHM, we know the pandemic is hard work – exhausting, even. SHM has been actively focused on supporting hospitalists during this crisis so that hospitalists can focus on patients. Early in the pandemic, SHM quickly pivoted to supply hospitalists with COVID-19 resources in their fight against the coronavirus. Numerous COVID-19 webinars, a COVID addendum to the State of Hospital Medicine Report, and a dedicated COVID issue of the Journal of Hospital Medicine were early and successful information dissemination strategies.

As the world – and hospitalists – dug in for a multi-year pandemic, SHM continued to advance the care of patients by opening our library of educational content for free to anyone. Our Public Policy Committee was active around both COVID-19- and hospitalist-related topics: immigration, telehealth, wellbeing, and financial impacts, to name a few.

As the pandemic slogged on, our Wellbeing Task Force came up with innovative support measures, including a check-in guide for hospitalists and fellow health care workers and dedicated wellness sessions complete with a licensed therapist for members. All the while, despite the restrictions and hurdles the pandemic has thrown our way, SHM members keep meeting and collaborating through virtual chapter events, committee work, special interest groups, and our annual conference, SHM Converge. Thank you to the countless members who donated their time to SHM, so that SHM could support hospitalists and their patients.

Now, we are transitioning into a new phase of the pandemic. The medical miracles that are the COVID-19 vaccines have made that possible. Fully vaccinated, I no longer worry that every time someone sneezes, or when I care for patients with a fever, that I am playing a high stakes poker game with my life. Don’t get me wrong; as I write, the Delta variant has a hold on the nation, and I know it’s not over yet. But it does appear as if the medical war on COVID is shifting from national to regional (or even local) responses.

During this new phase, we must rebuild our personal and professional lives. If you haven’t read Retired Lieutenant General Mark Hertling’s perspective piece in the August issue of the Journal of Hospital Medicine, I strongly encourage you to do so. He shares profound lessons on transitioning from active combat that are directly applicable to hospitalists who have been “deployed” battling COVID-19.

SHM will continue to pivot to meet our members’ needs too. We are already gearing up for more in-person education and networking. Chapters are starting to meet in person, and SHM is happy to provide visiting faculty. I will visit members from Florida to Maine and places in between starting this fall! Our Board of Directors and other SHM leaders are also starting to meet with members in person. Our own Leadership Academy will take place at Amelia Island in Florida in October, where we can learn, network, and even decompress. We also can’t wait for SHM Converge 2022 in Nashville, where we hope to reunite with many of you after 2 years of virtual conferences.

Our response to the pandemic, a once in a century crisis where our own safety was at risk, where doing the right thing might mean death or harming loved ones, our response of running into the fire to save lives is truly inspiring. The power of care – for our patients, for our family and friends, and for our hospital medicine community and the community at large – is evident more now than ever.

There have always been good reasons to be proud of being a hospitalist: taking care of the acutely ill, helping hospitals improve, teaching young doctors, and watching my specialty grow by leaps and bounds, to name just a few. But I’ve never been prouder than I am now.

Dr. Howell is the CEO of the Society of Hospital Medicine.

I have been a proud hospitalist for more than 20 years, and yet I have never been prouder to be a hospitalist than now. The pandemic has been brutal, killing more than 600,000 Americans as of this writing. It has stretched the health care system, its doctors, nurses, and other providers to the limit. Yet we will get through it, we are getting through it, and hospitalists deserve a huge portion of the credit.

According to the CDC, there have been over 2.3 million COVID-19 hospitalizations. In my home state of Maryland, between two-thirds and three-quarters of hospitalized COVID patients are cared for on general medical floors, the domain of hospitalists. When hospitals needed COVID units, hospitalists stepped up to design and staff them. When our ICU colleagues needed support, especially in those early dark days, hospitalists stepped in. When our outpatient colleagues were called into the hospital, hospitalists were there to help them on board. When the House of Medicine was in chaos due to COVID-19, hospitalists ran towards that fire. Our previous 20+ years of collective experience made us the ideal specialty to manage the inpatient challenges over the last 18 months.

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

Need a new way to teach residents and students on the wards? Check.

Need a whole new unit – no, wait – a new hospital wing? No, scratch that – a whole new COVID hospital in a few weeks? Check. (I personally did that last one at the Baltimore Convention Center!)

For me and many hospitalists like me, it is as if the last 20 years were prep work for the pandemic.

Here at SHM, we know the pandemic is hard work – exhausting, even. SHM has been actively focused on supporting hospitalists during this crisis so that hospitalists can focus on patients. Early in the pandemic, SHM quickly pivoted to supply hospitalists with COVID-19 resources in their fight against the coronavirus. Numerous COVID-19 webinars, a COVID addendum to the State of Hospital Medicine Report, and a dedicated COVID issue of the Journal of Hospital Medicine were early and successful information dissemination strategies.

As the world – and hospitalists – dug in for a multi-year pandemic, SHM continued to advance the care of patients by opening our library of educational content for free to anyone. Our Public Policy Committee was active around both COVID-19- and hospitalist-related topics: immigration, telehealth, wellbeing, and financial impacts, to name a few.

As the pandemic slogged on, our Wellbeing Task Force came up with innovative support measures, including a check-in guide for hospitalists and fellow health care workers and dedicated wellness sessions complete with a licensed therapist for members. All the while, despite the restrictions and hurdles the pandemic has thrown our way, SHM members keep meeting and collaborating through virtual chapter events, committee work, special interest groups, and our annual conference, SHM Converge. Thank you to the countless members who donated their time to SHM, so that SHM could support hospitalists and their patients.

Now, we are transitioning into a new phase of the pandemic. The medical miracles that are the COVID-19 vaccines have made that possible. Fully vaccinated, I no longer worry that every time someone sneezes, or when I care for patients with a fever, that I am playing a high stakes poker game with my life. Don’t get me wrong; as I write, the Delta variant has a hold on the nation, and I know it’s not over yet. But it does appear as if the medical war on COVID is shifting from national to regional (or even local) responses.

During this new phase, we must rebuild our personal and professional lives. If you haven’t read Retired Lieutenant General Mark Hertling’s perspective piece in the August issue of the Journal of Hospital Medicine, I strongly encourage you to do so. He shares profound lessons on transitioning from active combat that are directly applicable to hospitalists who have been “deployed” battling COVID-19.

SHM will continue to pivot to meet our members’ needs too. We are already gearing up for more in-person education and networking. Chapters are starting to meet in person, and SHM is happy to provide visiting faculty. I will visit members from Florida to Maine and places in between starting this fall! Our Board of Directors and other SHM leaders are also starting to meet with members in person. Our own Leadership Academy will take place at Amelia Island in Florida in October, where we can learn, network, and even decompress. We also can’t wait for SHM Converge 2022 in Nashville, where we hope to reunite with many of you after 2 years of virtual conferences.

Our response to the pandemic, a once in a century crisis where our own safety was at risk, where doing the right thing might mean death or harming loved ones, our response of running into the fire to save lives is truly inspiring. The power of care – for our patients, for our family and friends, and for our hospital medicine community and the community at large – is evident more now than ever.

There have always been good reasons to be proud of being a hospitalist: taking care of the acutely ill, helping hospitals improve, teaching young doctors, and watching my specialty grow by leaps and bounds, to name just a few. But I’ve never been prouder than I am now.

Dr. Howell is the CEO of the Society of Hospital Medicine.

Like many colleagues, I have been working to change the minds and behaviors of acquaintances and patients who are opting to forgo a COVID vaccine. The large numbers of these unvaccinated Americans, combined with the surging Delta coronavirus variant, are endangering the health of us all.

When I spoke with the 22-year-old daughter of a family friend about what was holding her back, she told me that she would “never” get vaccinated. I shared my vaccination experience and told her that, except for a sore arm both times for a day, I felt no side effects. Likewise, I said, all of my adult family members are vaccinated, and everyone is fine. She was neither moved nor convinced.

Finally, I asked her whether she attended school (knowing that she was a college graduate), and she said “yes.” So I told her that all 50 states require children attending public schools to be vaccinated for diseases such as diphtheria, tetanus, polio, and the chickenpox – with certain religious, philosophical, and medical exemptions. Her response was simple: “I didn’t know that. Anyway, my parents were in charge.” Suddenly, her thinking shifted. “You’re right,” she said. She got a COVID shot the next day. Success for me.

When I asked another acquaintance whether he’d been vaccinated, he said he’d heard people were getting very sick from the vaccine – and was going to wait. Another gentleman I spoke with said that, at age 45, he was healthy. Besides, he added, he “doesn’t get sick.” When I asked another acquaintance about her vaccination status, her retort was that this was none of my business. So far, I’m batting about .300.

But as a physician, I believe that we – and other health care providers – must continue to encourage the people in our lives to care for themselves and others by getting vaccinated. One concrete step advised by the Centers for Disease Control and Prevention is to help people make an appointment for a shot. Some sites no longer require appointments, and New York City, for example, offers in-home vaccinations to all NYC residents.

Also, NYC Mayor Bill de Blasio announced Aug. 3 the “Key to NYC Pass,” which he called a “first-in-the-nation approach” to vaccination. Under this new policy, vaccine-eligible people aged 12 and older in New York City will need to prove with a vaccination card, an app, or an Excelsior Pass that they have received at least one dose of vaccine before participating in indoor venues such as restaurants, bars, gyms, and movie theaters within the city. Mayor de Blasio said the new initiative, which is still being finalized, will be phased in starting the week of Aug. 16. I see this as a major public health measure that will keep people healthy – and get them vaccinated.

The medical community should support this move by the city of New York and encourage people to follow CDC guidance on wearing face coverings in public settings, especially schools. New research shows that physicians continue to be among the most trusted sources of vaccine-related information.

Another strategy we might use is to point to the longtime practices of surgeons. We could ask: Why do surgeons wear face masks in the operating room? For years, these coverings have been used to protect patients from the nasal and oral bacteria generated by operating room staff. Likewise, we can tell those who remain on the fence that, by wearing face masks, we are protecting others from all variants, but specifically from Delta – which the CDC now says can be transmitted by people who are fully vaccinated.

Why did the CDC lift face mask guidance for fully vaccinated people in indoor spaces in May? It was clear to me and other colleagues back then that this was not a good idea. Despite that guidance, I continued to wear a mask in public places and advised anyone who would listen to do the same.

The development of vaccines in the 20th and 21st centuries has saved millions of lives. The World Health Organization reports that 4 million to 5 million lives a year are saved by immunizations. In addition, research shows that, before the emergence of SARS-CoV-2, vaccinations led to the eradication of smallpox and polio, and a 74% drop in measles-related deaths between 2004 and 2014.
 

Protecting the most vulnerable

With COVID cases surging, particularly in parts of the South and Midwest, I am concerned about children under age 12 who do not yet qualify for a vaccine. Certainly, unvaccinated parents could spread the virus to their young children, and unvaccinated children could transmit the illness to immediate and extended family. Now that the CDC has said that there is a risk of SARS-CoV-2 breakthrough infection among fully vaccinated people in areas with high community transmission, should we worry about unvaccinated young children with vaccinated parents? I recently spoke with James C. Fagin, MD, a board-certified pediatrician and immunologist, to get his views on this issue.

Dr. Fagin, who is retired, said he is in complete agreement with the Food and Drug Administration when it comes to approving medications for children. However, given the seriousness of the pandemic and the need to get our children back to in-person learning, he would like to see the approval process safely expedited. Large numbers of unvaccinated people increase the pool for the Delta variant and could increase the likelihood of a new variant that is more resistant to the vaccines, said Dr. Fagin, former chief of academic pediatrics at North Shore University Hospital and a former faculty member in the allergy/immunology division of Cohen Children’s Medical Center, both in New York.

Meanwhile, I agree with the American Academy of Pediatrics’ recommendations that children, teachers, and school staff and other adults in school settings should wear masks regardless of vaccination status. Kids adjust well to masks – as my grandchildren and their friends have.

The bottom line is that we need to get as many people as possible vaccinated as soon as possible, and while doing so, we must continue to wear face coverings in public spaces. As clinicians, we have a special responsibility to do all that we can to change minds – and behaviors.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Like many colleagues, I have been working to change the minds and behaviors of acquaintances and patients who are opting to forgo a COVID vaccine. The large numbers of these unvaccinated Americans, combined with the surging Delta coronavirus variant, are endangering the health of us all.

When I spoke with the 22-year-old daughter of a family friend about what was holding her back, she told me that she would “never” get vaccinated. I shared my vaccination experience and told her that, except for a sore arm both times for a day, I felt no side effects. Likewise, I said, all of my adult family members are vaccinated, and everyone is fine. She was neither moved nor convinced.

Finally, I asked her whether she attended school (knowing that she was a college graduate), and she said “yes.” So I told her that all 50 states require children attending public schools to be vaccinated for diseases such as diphtheria, tetanus, polio, and the chickenpox – with certain religious, philosophical, and medical exemptions. Her response was simple: “I didn’t know that. Anyway, my parents were in charge.” Suddenly, her thinking shifted. “You’re right,” she said. She got a COVID shot the next day. Success for me.

When I asked another acquaintance whether he’d been vaccinated, he said he’d heard people were getting very sick from the vaccine – and was going to wait. Another gentleman I spoke with said that, at age 45, he was healthy. Besides, he added, he “doesn’t get sick.” When I asked another acquaintance about her vaccination status, her retort was that this was none of my business. So far, I’m batting about .300.

But as a physician, I believe that we – and other health care providers – must continue to encourage the people in our lives to care for themselves and others by getting vaccinated. One concrete step advised by the Centers for Disease Control and Prevention is to help people make an appointment for a shot. Some sites no longer require appointments, and New York City, for example, offers in-home vaccinations to all NYC residents.

Also, NYC Mayor Bill de Blasio announced Aug. 3 the “Key to NYC Pass,” which he called a “first-in-the-nation approach” to vaccination. Under this new policy, vaccine-eligible people aged 12 and older in New York City will need to prove with a vaccination card, an app, or an Excelsior Pass that they have received at least one dose of vaccine before participating in indoor venues such as restaurants, bars, gyms, and movie theaters within the city. Mayor de Blasio said the new initiative, which is still being finalized, will be phased in starting the week of Aug. 16. I see this as a major public health measure that will keep people healthy – and get them vaccinated.

The medical community should support this move by the city of New York and encourage people to follow CDC guidance on wearing face coverings in public settings, especially schools. New research shows that physicians continue to be among the most trusted sources of vaccine-related information.

Another strategy we might use is to point to the longtime practices of surgeons. We could ask: Why do surgeons wear face masks in the operating room? For years, these coverings have been used to protect patients from the nasal and oral bacteria generated by operating room staff. Likewise, we can tell those who remain on the fence that, by wearing face masks, we are protecting others from all variants, but specifically from Delta – which the CDC now says can be transmitted by people who are fully vaccinated.

Why did the CDC lift face mask guidance for fully vaccinated people in indoor spaces in May? It was clear to me and other colleagues back then that this was not a good idea. Despite that guidance, I continued to wear a mask in public places and advised anyone who would listen to do the same.

The development of vaccines in the 20th and 21st centuries has saved millions of lives. The World Health Organization reports that 4 million to 5 million lives a year are saved by immunizations. In addition, research shows that, before the emergence of SARS-CoV-2, vaccinations led to the eradication of smallpox and polio, and a 74% drop in measles-related deaths between 2004 and 2014.
 

Protecting the most vulnerable

With COVID cases surging, particularly in parts of the South and Midwest, I am concerned about children under age 12 who do not yet qualify for a vaccine. Certainly, unvaccinated parents could spread the virus to their young children, and unvaccinated children could transmit the illness to immediate and extended family. Now that the CDC has said that there is a risk of SARS-CoV-2 breakthrough infection among fully vaccinated people in areas with high community transmission, should we worry about unvaccinated young children with vaccinated parents? I recently spoke with James C. Fagin, MD, a board-certified pediatrician and immunologist, to get his views on this issue.

Dr. Fagin, who is retired, said he is in complete agreement with the Food and Drug Administration when it comes to approving medications for children. However, given the seriousness of the pandemic and the need to get our children back to in-person learning, he would like to see the approval process safely expedited. Large numbers of unvaccinated people increase the pool for the Delta variant and could increase the likelihood of a new variant that is more resistant to the vaccines, said Dr. Fagin, former chief of academic pediatrics at North Shore University Hospital and a former faculty member in the allergy/immunology division of Cohen Children’s Medical Center, both in New York.

Meanwhile, I agree with the American Academy of Pediatrics’ recommendations that children, teachers, and school staff and other adults in school settings should wear masks regardless of vaccination status. Kids adjust well to masks – as my grandchildren and their friends have.

The bottom line is that we need to get as many people as possible vaccinated as soon as possible, and while doing so, we must continue to wear face coverings in public spaces. As clinicians, we have a special responsibility to do all that we can to change minds – and behaviors.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.

Like many colleagues, I have been working to change the minds and behaviors of acquaintances and patients who are opting to forgo a COVID vaccine. The large numbers of these unvaccinated Americans, combined with the surging Delta coronavirus variant, are endangering the health of us all.

When I spoke with the 22-year-old daughter of a family friend about what was holding her back, she told me that she would “never” get vaccinated. I shared my vaccination experience and told her that, except for a sore arm both times for a day, I felt no side effects. Likewise, I said, all of my adult family members are vaccinated, and everyone is fine. She was neither moved nor convinced.

Finally, I asked her whether she attended school (knowing that she was a college graduate), and she said “yes.” So I told her that all 50 states require children attending public schools to be vaccinated for diseases such as diphtheria, tetanus, polio, and the chickenpox – with certain religious, philosophical, and medical exemptions. Her response was simple: “I didn’t know that. Anyway, my parents were in charge.” Suddenly, her thinking shifted. “You’re right,” she said. She got a COVID shot the next day. Success for me.

When I asked another acquaintance whether he’d been vaccinated, he said he’d heard people were getting very sick from the vaccine – and was going to wait. Another gentleman I spoke with said that, at age 45, he was healthy. Besides, he added, he “doesn’t get sick.” When I asked another acquaintance about her vaccination status, her retort was that this was none of my business. So far, I’m batting about .300.

But as a physician, I believe that we – and other health care providers – must continue to encourage the people in our lives to care for themselves and others by getting vaccinated. One concrete step advised by the Centers for Disease Control and Prevention is to help people make an appointment for a shot. Some sites no longer require appointments, and New York City, for example, offers in-home vaccinations to all NYC residents.

Also, NYC Mayor Bill de Blasio announced Aug. 3 the “Key to NYC Pass,” which he called a “first-in-the-nation approach” to vaccination. Under this new policy, vaccine-eligible people aged 12 and older in New York City will need to prove with a vaccination card, an app, or an Excelsior Pass that they have received at least one dose of vaccine before participating in indoor venues such as restaurants, bars, gyms, and movie theaters within the city. Mayor de Blasio said the new initiative, which is still being finalized, will be phased in starting the week of Aug. 16. I see this as a major public health measure that will keep people healthy – and get them vaccinated.

The medical community should support this move by the city of New York and encourage people to follow CDC guidance on wearing face coverings in public settings, especially schools. New research shows that physicians continue to be among the most trusted sources of vaccine-related information.

Another strategy we might use is to point to the longtime practices of surgeons. We could ask: Why do surgeons wear face masks in the operating room? For years, these coverings have been used to protect patients from the nasal and oral bacteria generated by operating room staff. Likewise, we can tell those who remain on the fence that, by wearing face masks, we are protecting others from all variants, but specifically from Delta – which the CDC now says can be transmitted by people who are fully vaccinated.

Why did the CDC lift face mask guidance for fully vaccinated people in indoor spaces in May? It was clear to me and other colleagues back then that this was not a good idea. Despite that guidance, I continued to wear a mask in public places and advised anyone who would listen to do the same.

The development of vaccines in the 20th and 21st centuries has saved millions of lives. The World Health Organization reports that 4 million to 5 million lives a year are saved by immunizations. In addition, research shows that, before the emergence of SARS-CoV-2, vaccinations led to the eradication of smallpox and polio, and a 74% drop in measles-related deaths between 2004 and 2014.
 

Protecting the most vulnerable

With COVID cases surging, particularly in parts of the South and Midwest, I am concerned about children under age 12 who do not yet qualify for a vaccine. Certainly, unvaccinated parents could spread the virus to their young children, and unvaccinated children could transmit the illness to immediate and extended family. Now that the CDC has said that there is a risk of SARS-CoV-2 breakthrough infection among fully vaccinated people in areas with high community transmission, should we worry about unvaccinated young children with vaccinated parents? I recently spoke with James C. Fagin, MD, a board-certified pediatrician and immunologist, to get his views on this issue.

Dr. Fagin, who is retired, said he is in complete agreement with the Food and Drug Administration when it comes to approving medications for children. However, given the seriousness of the pandemic and the need to get our children back to in-person learning, he would like to see the approval process safely expedited. Large numbers of unvaccinated people increase the pool for the Delta variant and could increase the likelihood of a new variant that is more resistant to the vaccines, said Dr. Fagin, former chief of academic pediatrics at North Shore University Hospital and a former faculty member in the allergy/immunology division of Cohen Children’s Medical Center, both in New York.

Meanwhile, I agree with the American Academy of Pediatrics’ recommendations that children, teachers, and school staff and other adults in school settings should wear masks regardless of vaccination status. Kids adjust well to masks – as my grandchildren and their friends have.

The bottom line is that we need to get as many people as possible vaccinated as soon as possible, and while doing so, we must continue to wear face coverings in public spaces. As clinicians, we have a special responsibility to do all that we can to change minds – and behaviors.

Dr. London is a practicing psychiatrist who has been a newspaper columnist for 35 years, specializing in and writing about short-term therapy, including cognitive-behavioral therapy and guided imagery. He is author of “Find Freedom Fast” (New York: Kettlehole Publishing, 2019). He has no conflicts of interest.