Opinion

 

It goes without saying that as a physician, it’s essential to keep your knowledge and skills current. But too many private practitioners overlook the similar needs of their employees.

Continuing education is as important for your staff as for you. Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

But there are lots of other good reasons to invest in ongoing staff training. It’s a win-win strategy for you, your staff, and for your practice.

The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. And the better their skills and the greater their confidence, the less supervision they need from you, and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees’ competence makes them feel valued and appreciated. This leads to reduced turnover – which, alone, often pays for the training.

You probably already do some ongoing education: You do your yearly OSHA training because the law requires it, you run HIPAA updates as necessary, and you have everyone recertified periodically in basic or advanced CPR (I hope). But I’m talking about going beyond the basic stuff, which may satisfy legal requirements, but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses – or at the very least, online refreshers – so they are always current on the latest third-party changes. The use of outdated or obsolete codes can cost you thousands of dollars every month. Other opportunities include keyboarding and computer courses for staff who work with your computers, and Excel and QuickBooks updates for your bookkeepers.

Continuing education does not have to be costly, and in some cases it can be free. For example, pharmaceutical representatives will be happy to run an in-service for your staff on a new medication or procedure or instrument, or refresh their memories on an established one. Be sure to make clear to the rep that the presentation must be as objective and impartial as possible, given the obvious potential conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators and Managers. It holds annual meetings at the same time and in the same city as the American Academy of Dermatology winter meetings, with a good selection of refresher courses and lots of opportunities for networking with other managers, both personally or virtually.

Many other venues are available for employee education, in the cloud and in conventional classrooms. Courses are offered in many relevant subjects; a quick Google search turns up an eclectic mix, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far the most common question I receive on this issue is, “What if I pay for all that training, and then the employees leave?”

My reply: “What if you don’t, and they stay?”

Well-trained employees are vastly preferable to untrained ones. I suppose there is some risk of an occasional staffer accepting training and then moving on; but in 38 years, it has never happened in my office. In my experience, well-trained employees will stay. Education fosters loyalty. Employees who know you care enough about them to advance their skills will sense that they have a stake in the practice, and thus will be less likely to want to leave. Furthermore, continuing education will always be cheaper than training new employees from scratch.

In any case, everyone will benefit from a well-trained staff – you, your employees, your practice, and most importantly your patients.
 

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

 

It goes without saying that as a physician, it’s essential to keep your knowledge and skills current. But too many private practitioners overlook the similar needs of their employees.

Continuing education is as important for your staff as for you. Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

But there are lots of other good reasons to invest in ongoing staff training. It’s a win-win strategy for you, your staff, and for your practice.

The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. And the better their skills and the greater their confidence, the less supervision they need from you, and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees’ competence makes them feel valued and appreciated. This leads to reduced turnover – which, alone, often pays for the training.

You probably already do some ongoing education: You do your yearly OSHA training because the law requires it, you run HIPAA updates as necessary, and you have everyone recertified periodically in basic or advanced CPR (I hope). But I’m talking about going beyond the basic stuff, which may satisfy legal requirements, but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses – or at the very least, online refreshers – so they are always current on the latest third-party changes. The use of outdated or obsolete codes can cost you thousands of dollars every month. Other opportunities include keyboarding and computer courses for staff who work with your computers, and Excel and QuickBooks updates for your bookkeepers.

Continuing education does not have to be costly, and in some cases it can be free. For example, pharmaceutical representatives will be happy to run an in-service for your staff on a new medication or procedure or instrument, or refresh their memories on an established one. Be sure to make clear to the rep that the presentation must be as objective and impartial as possible, given the obvious potential conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators and Managers. It holds annual meetings at the same time and in the same city as the American Academy of Dermatology winter meetings, with a good selection of refresher courses and lots of opportunities for networking with other managers, both personally or virtually.

Many other venues are available for employee education, in the cloud and in conventional classrooms. Courses are offered in many relevant subjects; a quick Google search turns up an eclectic mix, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far the most common question I receive on this issue is, “What if I pay for all that training, and then the employees leave?”

My reply: “What if you don’t, and they stay?”

Well-trained employees are vastly preferable to untrained ones. I suppose there is some risk of an occasional staffer accepting training and then moving on; but in 38 years, it has never happened in my office. In my experience, well-trained employees will stay. Education fosters loyalty. Employees who know you care enough about them to advance their skills will sense that they have a stake in the practice, and thus will be less likely to want to leave. Furthermore, continuing education will always be cheaper than training new employees from scratch.

In any case, everyone will benefit from a well-trained staff – you, your employees, your practice, and most importantly your patients.
 

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

 

It goes without saying that as a physician, it’s essential to keep your knowledge and skills current. But too many private practitioners overlook the similar needs of their employees.

Continuing education is as important for your staff as for you. Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

But there are lots of other good reasons to invest in ongoing staff training. It’s a win-win strategy for you, your staff, and for your practice.

The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. And the better their skills and the greater their confidence, the less supervision they need from you, and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees’ competence makes them feel valued and appreciated. This leads to reduced turnover – which, alone, often pays for the training.

You probably already do some ongoing education: You do your yearly OSHA training because the law requires it, you run HIPAA updates as necessary, and you have everyone recertified periodically in basic or advanced CPR (I hope). But I’m talking about going beyond the basic stuff, which may satisfy legal requirements, but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses – or at the very least, online refreshers – so they are always current on the latest third-party changes. The use of outdated or obsolete codes can cost you thousands of dollars every month. Other opportunities include keyboarding and computer courses for staff who work with your computers, and Excel and QuickBooks updates for your bookkeepers.

Continuing education does not have to be costly, and in some cases it can be free. For example, pharmaceutical representatives will be happy to run an in-service for your staff on a new medication or procedure or instrument, or refresh their memories on an established one. Be sure to make clear to the rep that the presentation must be as objective and impartial as possible, given the obvious potential conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators and Managers. It holds annual meetings at the same time and in the same city as the American Academy of Dermatology winter meetings, with a good selection of refresher courses and lots of opportunities for networking with other managers, both personally or virtually.

Many other venues are available for employee education, in the cloud and in conventional classrooms. Courses are offered in many relevant subjects; a quick Google search turns up an eclectic mix, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far the most common question I receive on this issue is, “What if I pay for all that training, and then the employees leave?”

My reply: “What if you don’t, and they stay?”

Well-trained employees are vastly preferable to untrained ones. I suppose there is some risk of an occasional staffer accepting training and then moving on; but in 38 years, it has never happened in my office. In my experience, well-trained employees will stay. Education fosters loyalty. Employees who know you care enough about them to advance their skills will sense that they have a stake in the practice, and thus will be less likely to want to leave. Furthermore, continuing education will always be cheaper than training new employees from scratch.

In any case, everyone will benefit from a well-trained staff – you, your employees, your practice, and most importantly your patients.
 

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

 

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

 

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

 

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

 

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

 

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

 

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

 

“I need to get out of here! I haven’t gotten any sleep, my medications never come on time, and I feel like a pincushion. I am leaving NOW!” The commotion interrupts your intern’s meticulous presentation as your team quickly files into the room. You find a disheveled, visibly frustrated man tearing at his intravenous line, surrounded by his half-eaten breakfast and multiple urinals filled to various levels. His IV pump is beeping, and telemetry wires hang haphazardly off his chest.

Mr. Smith had been admitted for a heart failure exacerbation. You’d been making steady progress with diuresis but are now faced with a likely discharge against medical advice if you can’t defuse the situation.

As hospitalists, this scenario might feel eerily familiar. Perhaps Mr. Smith had enough of being in the hospital and just wanted to go home to see his dog, or maybe the food was not up to his standards.

However, his next line stops your team dead in its tracks. “I feel like I am in Vietnam all over again. I am tied up with all these wires and feel like a prisoner! Please let me go.” It turns out that Mr. Smith had a comorbidity that was overlooked during his initial intake: posttraumatic stress disorder.

Impact of PTSD

PTSD is a diagnosis characterized by intrusive recurrent thoughts, dreams, or flashbacks that follow exposure to a traumatic event or series of events (see Table 1). While more common among veterans (for example, Vietnam veterans have an estimated lifetime prevalence of PTSD of 30.9% for men and 26.9% for women),¹ a national survey of U.S. households estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%.² PTSD is often underdiagnosed and underreported by patients in the outpatient setting, leading to underrecognition and undertreatment of these patients in the inpatient setting.

Although it may not be surprising that patients with PTSD use more mental health services, they are also more likely to use nonmental health services. In one study, total utilization of outpatient nonmental health services was 91% greater in veterans with PTSD, and these patients were three times more likely to be hospitalized than those without any mental health diagnoses.³ Additionally, they are likely to present later and stay longer when compared with patients without PTSD. One study estimated the cost of PTSD-related hospitalization in the United States from 2002 to 2011 as being $34.9 billion.⁴ Notably, close to 95% of hospitalizations in this study listed PTSD as a secondary rather than primary diagnosis, suggesting that the vast majority of these admitted patients are cared for by frontline providers who are not trained mental health professionals.

How PTSD manifests in the hospital

But, how exactly can the hospital environment contribute to decompensation of PTSD symptoms? Unfortunately, there is little empiric data to guide us. Based on what we do know of PTSD, we offer the following hypotheses.

 

Patients with PTSD may feel a loss of control or helplessness when admitted to the inpatient setting. For example, they cannot control when they receive their medications or when they get their meals. The act of showering or going outside requires approval. In addition, they might perceive they are being “ordered around” by staff and may be carted off to a study without knowing why the study is being done in the first place.

Triggers in the hospital environment may contribute to PTSD flares. Think about the loud, beeping IV pump that constantly goes off at random intervals, disrupting sleep. What about a blood draw in the early morning where the phlebotomist sticks a needle into the arm of a sleeping patient? Or the well-intentioned provider doing prerounds who wakes a sleeping patient with a shake of the shoulder or some other form of physical touch? The multidisciplinary team crowding around their hospital bed? For a patient suffering from PTSD, any of these could easily set off a cascade of escalating symptoms.

Knowing that these triggers exist, can anything be done to ameliorate their effects? We propose some practical suggestions for improving the hospital experience for patients with PTSD.

Strategies to combat PTSD in the inpatient setting

Perhaps the most practical place to start is with preserving sleep in hospitalized patients with PTSD. The majority of patients with PTSD have sleep disturbances, and interrupted sleep routines in these patients can exacerbate nightmares and underlying psychiatric issues.⁵ Therefore, we should strive to avoid unnecessary awakenings.

While this principle holds true for all hospitalized patients, it must be especially prioritized in patients with PTSD. Ask yourself these questions during your next admission: Must intravenous fluids run 24 hours a day, or could they be stopped at 6 p.m.? Are vital signs needed overnight? Could the last dose of furosemide occur at 4 p.m. to avoid nocturia?

Another strategy involves bedtime routines. Many of these patients may already follow a home sleep routine as part of their chronic PTSD management. To honor these habits in the hospital might mean that staff encourage turning the lights and the television off at a designated time. Additionally, the literature suggests music therapy can have a significant impact on enhanced sleep quality. When available, music therapy may reduce insomnia and decrease the amount of time prior to falling asleep.⁶

Other methods to counteract PTSD fall under the general principle of “trauma-informed care.” Trauma-informed care comprises practices promoting a culture of safety, empowerment, and healing.⁷ It is a mindful and sensitive approach that acknowledges the pervasive nature of trauma exposure, the reality of ongoing adverse effects in trauma survivors, and the fact that recovery is highly personal and complex.⁸

By definition, patients with PTSD have endured some traumatic event. Therefore, ideal care teams will ask patients about things that may trigger their anxiety and then work to mitigate them. For example, some patients with PTSD have a severe startle response when woken up by someone touching them. When patients feel that they can share their concerns with their care team and their team honors that observation by waking them in a different way, trust and control may be gained. This process of asking for patient guidance and adjusting accordingly is consistent with a trauma-informed care approach.⁹ A true trauma-informed care approach involves the entire practice environment but examining and adjusting our own behavior and assumptions are good places to start.

 

Summary of recommended treatments

Psychotherapy is preferable over pharmacotherapy, but both can be combined as needed. Individual trauma-focused psychotherapies utilizing a primary component of exposure and/or cognitive restructuring have strong evidence for effectiveness but are primarily outpatient based.

For pharmacologic treatment, selective serotonin reuptake inhibitors (for example, sertraline, paroxetine, or fluoxetine) and serotonin norepinephrine reuptake inhibitors (for example, venlafaxine) monotherapy have strong evidence for effectiveness and can be started while inpatient. However, these medications typically take weeks to produce benefits. Recent trials studying prazosin, an alpha1-adrenergic receptor antagonist used to alleviate nightmares associated with PTSD, have demonstrated inefficacy or even harm,leading experts to caution against its use.^10,11 Finally, benzodiazepine and atypical antipsychotic usage should be restricted and used as a last resort.¹²

In summary, PTSD is common among veterans and nonveterans. While hospitalists may rarely admit patients because of their PTSD, they will often take care of patients who have PTSD as a comorbidity. Therefore, understanding the basics of PTSD and how hospitalization may exacerbate its symptoms can meaningfully improve care for these patients.

Dr. Fletcher is a hospitalist at the Milwaukee Veterans Affairs Medical Center and Froedtert Hospital in Wauwatosa, Wis. She is professor of internal medicine and program director for the internal medicine residency program at the Medical College of Wisconsin, Milwaukee. She is also faculty mentor for the VA’s Chief Resident for Quality and Safety. Dr. Kwan is a hospitalist at the VA San Diego Healthcare System and is associate professor at the University of California, San Diego, in the division of hospital medicine. He serves as an associate clerkship director of both the internal medicine clerkship and the medicine subinternship. He is the chair of SHM’s Physicians in Training committee. Dr. Steinbach is chief of hospital medicine at the Atlanta VA Medical Center and assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

References

1. Kang HK et al. Posttraumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141-8.

2. Kessler RC et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602.

3. Cohen BE et al. Mental health diagnoses and utilization of VA nonmental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

4. Haviland MG et al. Posttraumatic stress disorder–related hospitalizations in the United States (2002-2011): Rates, co-occurring illnesses, suicidal ideation/self-harm, and hospital charges. J Nerv Ment Dis. 2016; 204(2):78-86.

5. Aurora RN et al. Best practice guide for the treatment of nightmare disorder in adults. J Clin Sleep Med. 2010;6(4):389-401.

6. Blanaru M et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Ment Illn. 2012;4(2):e13.

7. Tello M. (2018, Oct 16). Trauma-informed care: What it is, and why it’s important. Retrieved March 18, 2019, from https://www.health.harvard.edu/blog/trauma-informed-care-what-it-is-and-why-its-important-2018101613562.

8. Harris M et al. Using trauma theory to design service systems. San Francisco: 2001.

9. Substance abuse and mental health services administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS publication no. SMA 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014.

10. Raskind MA et al. Trial of prazosin for posttraumatic stress disorder in military veterans. N Engl J Med. 2018 Feb 8;378(6):507-7.

11. McCall WV et al. A pilot, randomized clinical trial of bedtime doses of prazosin versus placebo in suicidal posttraumatic stress disorder patients with nightmares. J Clin Psychopharmacol. 2018 Dec;38(6):618-21.

12. U.S. Department of Veterans Affairs/U.S. Department of Defense. Clinical practice guideline for the management of posttraumatic stress disorder and acute stress reaction 2017. Accessed February 18, 2019.

 

As psychiatry mourns Carl Compton Bell, MD, a giant in our field, we pay homage to his legacy of leadership and productivity.

Dr. Bell wore many hats: community psychiatrist par excellence, award-winning researcher, clinician, public health advocate, mentor, and activist. Eschewing the mold of the stereotypical psychiatrist, he lectured in cowboy hats, baseball caps, message T-shirts, and shades – all conveying his youthful, down-to-earth, yet serious, psychiatrist-of-the-people style. He demonstrated that scholarship could combat racial inequities and made it clear that he had much to accomplish yet little to prove.

Dr. Bell implored physicians to not only treat health problems but also to rectify “upstream” issues. He encouraged their engagement in “bent-nail research,” empirical study directly in the communities where they work – even with limited resources. This approach, rooted in public health and prevention, undergirds his groundbreaking work in the treatment of fetal alcohol exposure with choline and folic acid. HIV prevention in South Africa was another area of study where he developed innovative strategies with successful outcomes. In his study of trauma in youth, he underscored that “risk factors are not predictive factors because of protective factors.”

He promoted social fabric, an adult protective shield, connectedness, self-esteem, self-efficacy, and social skills as protective. He understood that, with treatment and community supports, children exposed to violence were not doomed to a life of aberrant behavior.

A prolific author, Dr. Bell’s peer-reviewed articles are often cited and have become the gospel for community mental health. He bemoaned the insufficient translation of published research into reality in the community. His writings suggested that psychiatry should not assume that its standards of diagnosis and treatment apply entirely to nonwhite populations. This fact remains a call to action for those of us he leaves behind.

As a clinician, Dr. Bell listened intently to his patients to understand their current situations, histories, family histories, and contexts in which they lived. He was so dedicated to their care that, when a mental health center he led for years abruptly closed its doors, he set up a makeshift office on the front sidewalk to serve patients who might not have known about its closure.

Dr. Bell was active in organized psychiatry, serving as past chair of the American Psychiatric Association Council on Social Issues and Public Psychiatry. He inspired the creation of the APA’s Transformational Leadership in Public Psychiatry Fellowship for early- and mid-career psychiatrists. A loyal member of the Black Psychiatrists of America, he took pride in having saved all of BPA’s newsletters dating back to its founding in 1969.

His participation in those associations and in the National Medical Association was an avenue through which his robust scholarship encouraged the next generations of black psychiatrists. Those countless psychiatrists who trusted Dr. Bell’s wise counsel have gone on to become leaders. They are proof that his extraordinary accomplishments and spirit will live on through the multiplier effect of their contributions to the field and mentorship of future psychiatrists for years to come.
 

 

Dr. Gordon-Achebe is a child, adolescent, and adult psychiatrist practicing in the Baltimore metropolitan area. She is the immediate past president of the American Psychiatric Association’s Caucus of Black Psychiatrists and vice chair for the Council on Children, Adolescents and Their Families.

Dr. Hairston is the psychiatry residency training director at Howard University in Washington. She is the newly elected president of the American Psychiatric Association’s Caucus of Black Psychiatrists and the scientific program committee chair for the Black Psychiatrists of America.

Dr. Starks is a geriatric psychiatrist and Health and Aging Policy Fellow currently working on Capitol Hill in Washington. He is the representative to the assembly for the APA Caucus of Black Psychiatrists. He has nurtured a keen interest in understanding the cultural and social effects of geriatric mental health conditions on the lives of patients and families.

Dr. Primm, a community psychiatrist based in Baltimore, is senior medical director of the Steve Fund, which is focused on the mental health and emotional well-being of young people of color, including college students. She formerly served as deputy medical director of the APA and director of APA’s division of diversity and health equity, previously known as the Office of Minority and National Affairs.

 

As psychiatry mourns Carl Compton Bell, MD, a giant in our field, we pay homage to his legacy of leadership and productivity.

Dr. Bell wore many hats: community psychiatrist par excellence, award-winning researcher, clinician, public health advocate, mentor, and activist. Eschewing the mold of the stereotypical psychiatrist, he lectured in cowboy hats, baseball caps, message T-shirts, and shades – all conveying his youthful, down-to-earth, yet serious, psychiatrist-of-the-people style. He demonstrated that scholarship could combat racial inequities and made it clear that he had much to accomplish yet little to prove.

Dr. Bell implored physicians to not only treat health problems but also to rectify “upstream” issues. He encouraged their engagement in “bent-nail research,” empirical study directly in the communities where they work – even with limited resources. This approach, rooted in public health and prevention, undergirds his groundbreaking work in the treatment of fetal alcohol exposure with choline and folic acid. HIV prevention in South Africa was another area of study where he developed innovative strategies with successful outcomes. In his study of trauma in youth, he underscored that “risk factors are not predictive factors because of protective factors.”

He promoted social fabric, an adult protective shield, connectedness, self-esteem, self-efficacy, and social skills as protective. He understood that, with treatment and community supports, children exposed to violence were not doomed to a life of aberrant behavior.

A prolific author, Dr. Bell’s peer-reviewed articles are often cited and have become the gospel for community mental health. He bemoaned the insufficient translation of published research into reality in the community. His writings suggested that psychiatry should not assume that its standards of diagnosis and treatment apply entirely to nonwhite populations. This fact remains a call to action for those of us he leaves behind.

As a clinician, Dr. Bell listened intently to his patients to understand their current situations, histories, family histories, and contexts in which they lived. He was so dedicated to their care that, when a mental health center he led for years abruptly closed its doors, he set up a makeshift office on the front sidewalk to serve patients who might not have known about its closure.

Dr. Bell was active in organized psychiatry, serving as past chair of the American Psychiatric Association Council on Social Issues and Public Psychiatry. He inspired the creation of the APA’s Transformational Leadership in Public Psychiatry Fellowship for early- and mid-career psychiatrists. A loyal member of the Black Psychiatrists of America, he took pride in having saved all of BPA’s newsletters dating back to its founding in 1969.

His participation in those associations and in the National Medical Association was an avenue through which his robust scholarship encouraged the next generations of black psychiatrists. Those countless psychiatrists who trusted Dr. Bell’s wise counsel have gone on to become leaders. They are proof that his extraordinary accomplishments and spirit will live on through the multiplier effect of their contributions to the field and mentorship of future psychiatrists for years to come.
 

 

Dr. Gordon-Achebe is a child, adolescent, and adult psychiatrist practicing in the Baltimore metropolitan area. She is the immediate past president of the American Psychiatric Association’s Caucus of Black Psychiatrists and vice chair for the Council on Children, Adolescents and Their Families.

Dr. Hairston is the psychiatry residency training director at Howard University in Washington. She is the newly elected president of the American Psychiatric Association’s Caucus of Black Psychiatrists and the scientific program committee chair for the Black Psychiatrists of America.

Dr. Starks is a geriatric psychiatrist and Health and Aging Policy Fellow currently working on Capitol Hill in Washington. He is the representative to the assembly for the APA Caucus of Black Psychiatrists. He has nurtured a keen interest in understanding the cultural and social effects of geriatric mental health conditions on the lives of patients and families.

Dr. Primm, a community psychiatrist based in Baltimore, is senior medical director of the Steve Fund, which is focused on the mental health and emotional well-being of young people of color, including college students. She formerly served as deputy medical director of the APA and director of APA’s division of diversity and health equity, previously known as the Office of Minority and National Affairs.

 

As psychiatry mourns Carl Compton Bell, MD, a giant in our field, we pay homage to his legacy of leadership and productivity.

Dr. Bell wore many hats: community psychiatrist par excellence, award-winning researcher, clinician, public health advocate, mentor, and activist. Eschewing the mold of the stereotypical psychiatrist, he lectured in cowboy hats, baseball caps, message T-shirts, and shades – all conveying his youthful, down-to-earth, yet serious, psychiatrist-of-the-people style. He demonstrated that scholarship could combat racial inequities and made it clear that he had much to accomplish yet little to prove.

Dr. Bell implored physicians to not only treat health problems but also to rectify “upstream” issues. He encouraged their engagement in “bent-nail research,” empirical study directly in the communities where they work – even with limited resources. This approach, rooted in public health and prevention, undergirds his groundbreaking work in the treatment of fetal alcohol exposure with choline and folic acid. HIV prevention in South Africa was another area of study where he developed innovative strategies with successful outcomes. In his study of trauma in youth, he underscored that “risk factors are not predictive factors because of protective factors.”

He promoted social fabric, an adult protective shield, connectedness, self-esteem, self-efficacy, and social skills as protective. He understood that, with treatment and community supports, children exposed to violence were not doomed to a life of aberrant behavior.

A prolific author, Dr. Bell’s peer-reviewed articles are often cited and have become the gospel for community mental health. He bemoaned the insufficient translation of published research into reality in the community. His writings suggested that psychiatry should not assume that its standards of diagnosis and treatment apply entirely to nonwhite populations. This fact remains a call to action for those of us he leaves behind.

As a clinician, Dr. Bell listened intently to his patients to understand their current situations, histories, family histories, and contexts in which they lived. He was so dedicated to their care that, when a mental health center he led for years abruptly closed its doors, he set up a makeshift office on the front sidewalk to serve patients who might not have known about its closure.

Dr. Bell was active in organized psychiatry, serving as past chair of the American Psychiatric Association Council on Social Issues and Public Psychiatry. He inspired the creation of the APA’s Transformational Leadership in Public Psychiatry Fellowship for early- and mid-career psychiatrists. A loyal member of the Black Psychiatrists of America, he took pride in having saved all of BPA’s newsletters dating back to its founding in 1969.

His participation in those associations and in the National Medical Association was an avenue through which his robust scholarship encouraged the next generations of black psychiatrists. Those countless psychiatrists who trusted Dr. Bell’s wise counsel have gone on to become leaders. They are proof that his extraordinary accomplishments and spirit will live on through the multiplier effect of their contributions to the field and mentorship of future psychiatrists for years to come.
 

 

Dr. Gordon-Achebe is a child, adolescent, and adult psychiatrist practicing in the Baltimore metropolitan area. She is the immediate past president of the American Psychiatric Association’s Caucus of Black Psychiatrists and vice chair for the Council on Children, Adolescents and Their Families.

Dr. Hairston is the psychiatry residency training director at Howard University in Washington. She is the newly elected president of the American Psychiatric Association’s Caucus of Black Psychiatrists and the scientific program committee chair for the Black Psychiatrists of America.

Dr. Starks is a geriatric psychiatrist and Health and Aging Policy Fellow currently working on Capitol Hill in Washington. He is the representative to the assembly for the APA Caucus of Black Psychiatrists. He has nurtured a keen interest in understanding the cultural and social effects of geriatric mental health conditions on the lives of patients and families.

Dr. Primm, a community psychiatrist based in Baltimore, is senior medical director of the Steve Fund, which is focused on the mental health and emotional well-being of young people of color, including college students. She formerly served as deputy medical director of the APA and director of APA’s division of diversity and health equity, previously known as the Office of Minority and National Affairs.

 

It’s Monday morning, and your intern is presenting an overnight admission. Lost in the details of his disorganized introduction, your mind wanders. “Why doesn’t this intern know how to present? When I trained, all those admissions during long sleepless nights really taught me to do this right.” But can we equate hours worked with competency achieved? And if not, what is the alternative? This article introduces some major changes in medical education and their implications for hospitalists.

Most hospitalists trained in an educational system influenced by Sir William Osler. In the early 1900s, he introduced the natural method of teaching, positing that student exposure to patients and experience over time ensured that physicians in training would become competent doctors.¹ His influence led to the current structure of medical education, which includes conventional third-year clerkships and time-limited rotations (such as a 2-week nephrology block).

While familiarity may be comforting, there are signs our current model of medical education is inefficient, inadequate, and obsolete.

For one, the traditional system is failing to adequately prepare physicians to provide safe and complex care. Reports, such as the Institute of Medicine’s (IOM) “To Err is Human,”² describe a high rate of preventable errors, highlighting considerable room for improvement in training the next generation of physicians.^3,4

Meanwhile, trainees are still largely being deemed ready for the workforce by length of training completed (for example, completion of four-year medical school) rather than a skill set distinctly achieved. Our system leaves little flexibility to individualize learner goals, which is significant given some students and residents take shorter or longer periods of time to achieve proficiency. In addition, learner outcomes can be quite variable, as we have all experienced.

Even our methods of assessment may not adequately evaluate trainees’ skill sets. For example, most clerkships still rely heavily on the shelf exam⁵ as a surrogate for medical knowledge. As such, learners may conclude that testing performance trumps development of other professional skills.⁶ Efforts are being made to revamp evaluation systems to reflect mastery (such as Entrustable Professional Activities, or EPAs) toward competencies.⁷ Still, many institutions continue to rely on faculty evaluations that often reflect interpersonal dynamics rather than true critical thinking skills.⁶

Recognizing the above limitations, many educators have called for changing to outcome-based, or competency-based, training (CBME). CBME targets attainment of skills in performing concrete critical clinical activities,⁸ such as identifying unstable patients, providing initial management, and obtaining help. To be successful, supervisors must directly observe trainees, assess demonstrated skills, and provide feedback about progress.

Unfortunately, this considerable investment of time and effort is often poorly compensated. Additionally, unanswered questions remain. For example, how will residency programs continue to challenge physicians deemed “competent” in a required skill? What happens when a trainee is deficient and not appropriately progressing in a required skill? Is flexible training time part of the future of medical education? While CBME appears to be a more effective method of education, questions like these must be addressed during implementation.

Beyond the fact that hours worked cannot be used as a surrogate for competency, excessive unregulated work hours can be detrimental to learners, their supervisors, and patients. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major change in medical education: duty hour limitations. The premise that sleep-deprived providers are more prone to error is well established. However, controversy remains as to whether these regulations translate into improved patient care and provider well-being. Studies published following the ACGME change demonstrate increasing burnout among physicians,^9-11 which has led some educators to explore the potential relationship between burnout and duty hour restrictions.

The recent “iCOMPARE” trial, which compared internal medicine (IM) residencies with “standard duty-hour” policies to those with “flexible” policies (that is, they did not specify limits on shift length or mandatory time off between shifts), supported a lack of correlation between hours worked and burnout.¹² Researchers administered the Maslach Burnout Inventory to all participants.¹³ While those in the “flexible hours” arm reported greater dissatisfaction with the effect of the program on their personal lives, both groups reported significant burnout, with interns recording high scores in emotional exhaustion (79% in flexible programs vs. 72% in standard), depersonalization (75% vs. 72%), and lack of personal accomplishment (71% vs. 69%).

Disturbingly, these scores were not restricted to interns but were present in all residents. The good news? Limiting duty hours does not cause burnout. On the other hand, it does not protect from burnout. Trainee burnout appears to transcend the issue of hours worked. Clearly, we need to address the systemic flaws in our work environments that contribute to this epidemic. Nationwide, educators and organizations are continuing to define causes of burnout and test interventions to improve wellness.

A final front of change in medical education worth mentioning is the use of the electronic medical record (EMR). While the EMR has improved many aspects of patient care, its implementation is associated with decreased time spent with patients and parallels the rise in burnout. Another unforeseen consequence has been its disruptive impact on medical student documentation. A national survey of clerkship directors found that, while 64% of programs allowed students to use the EMR, only two-thirds of those programs permitted students to document electronically.¹⁴

Many institutions limit student access because of either liability concerns or the fact that student notes cannot be used to support medical billing. Concerning workarounds among preceptors, such as logging in students under their own credentials to write notes, have been identified.¹⁵ Yet medical students need to learn how to document a clinical encounter and maintain medical records.^7,16 Authoring notes engages students, promotes a sense of patient ownership, and empowers them to feel like essential team members. Participating in the EMR also allows for critical feedback and skill development.

In 2016, the Society of Hospital Medicine joined several major internal medicine organizations in asking the federal government to reconsider guidelines prohibiting attendings from referring to medical student notes. In February 2018, the Centers for Medicare & Medicaid Services (CMS) revised its student documentation guidelines (see Box A), allowing teaching physicians to use all student documentation (not just Review of Systems, Family History, and Social History) for billable services.

While the guidelines officially went into effect in March 2018, many institutions are still fine-tuning their implementation, in part because of nonspecific policy language. For instance, if a student composes a note and a resident edits and signs it, can the attending physician simply cosign the resident note? Also, once a student has presented a case, can the attending see the patient and verify findings without the student present?

Despite the above challenges, the revision to CMS guidelines is a significant “win” and can potentially reduce the documentation burden on teaching physicians. With more oversight of their notes, the next generation of students will be encouraged to produce accurate, high-quality documentation.

In summary, these changes in the way we define competency, in duty hours, and in the use of the EMR demonstrate that medical education is continuously improving via robust critique and educator engagement in outcomes. We are fortunate to train in a system that respects the scientific method and utilizes data and critical events to drive important changes in practice. Understanding these changes might help hospitalists relate to the backgrounds and needs of learners. And who knows – maybe next time that intern will do a better job presenting!
 

Dr. Kwan is a hospitalist at the Veterans Affairs San Diego Healthcare System (VASDHS) and an associate professor at the University of California, San Diego, in the division of hospital medicine. He is the chair of the SHM Physicians in Training committee. Dr. Sebasky is an associate clinical professor at UCSD in the division of hospital medicine. Dr. Muchmore is a hematologist/oncologist and professor of clinical medicine in the department of medicine at UCSD and associate chief of staff for education at VASDHS.

References

1. Osler W. “The Hospital as a College.” In Aequanimitas. Osler W, Ed. (Philadelphia: P. Blakiston’s Son & Co., 1932).

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health Care System. (Washington: National Academies Press, 1999).

3. Ten Cate O. Competency-based postgraduate medical education: Past, present and future. GMS J Med Educ. 2017 Nov 15. doi: 10.3205/zma001146.

4. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician–educators. Acad Med. 2016;91(5):645-9.

5. 2016 NBME Clinical Clerkship Subject Examination Survey.

6. Mehta NB, Hull AL, Young JB, et al. Just imagine: New paradigms for medical education. Acad Med. 2013;88(10):1418-23.

7. Fazio SB, Ledford CH, Aronowitz PB, et al. Competency-based medical education in the internal medicine clerkship: A report from the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force. Acad Med. 2018;93(3):421-7.

8. Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007 Jun;82(6):542-7.

9. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open. 2017. doi: 10.1136/bmjopen-2016-015141.

10. Hall LH, Johnson J, Watt I, et al. Healthcare Staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE. 2016. doi: 10.1371/journal.pone.0159015.

11. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Gen Intern Med. 2017 Apr; 32(4):475-82.

12. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty hour flexibility trial in internal medicine. N Engl J Med. 2018 378:1494-508.

13. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. 3rd ed. (Palo Alto, CA: Consulting Psychologists Press, 1996).

14. Hammoud MM, Margo K, Christner JG, et al. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-24.

15. White J, Anthony D, WinklerPrins V, et al. Electronic medical records, medical students, and ambulatory family physicians: A multi-institution study. Acad Med. 2017;92(10):1485-90.

16. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310(21):2249-50.
 

Box A

“Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
 

 

It’s Monday morning, and your intern is presenting an overnight admission. Lost in the details of his disorganized introduction, your mind wanders. “Why doesn’t this intern know how to present? When I trained, all those admissions during long sleepless nights really taught me to do this right.” But can we equate hours worked with competency achieved? And if not, what is the alternative? This article introduces some major changes in medical education and their implications for hospitalists.

Most hospitalists trained in an educational system influenced by Sir William Osler. In the early 1900s, he introduced the natural method of teaching, positing that student exposure to patients and experience over time ensured that physicians in training would become competent doctors.¹ His influence led to the current structure of medical education, which includes conventional third-year clerkships and time-limited rotations (such as a 2-week nephrology block).

While familiarity may be comforting, there are signs our current model of medical education is inefficient, inadequate, and obsolete.

For one, the traditional system is failing to adequately prepare physicians to provide safe and complex care. Reports, such as the Institute of Medicine’s (IOM) “To Err is Human,”² describe a high rate of preventable errors, highlighting considerable room for improvement in training the next generation of physicians.^3,4

Meanwhile, trainees are still largely being deemed ready for the workforce by length of training completed (for example, completion of four-year medical school) rather than a skill set distinctly achieved. Our system leaves little flexibility to individualize learner goals, which is significant given some students and residents take shorter or longer periods of time to achieve proficiency. In addition, learner outcomes can be quite variable, as we have all experienced.

Even our methods of assessment may not adequately evaluate trainees’ skill sets. For example, most clerkships still rely heavily on the shelf exam⁵ as a surrogate for medical knowledge. As such, learners may conclude that testing performance trumps development of other professional skills.⁶ Efforts are being made to revamp evaluation systems to reflect mastery (such as Entrustable Professional Activities, or EPAs) toward competencies.⁷ Still, many institutions continue to rely on faculty evaluations that often reflect interpersonal dynamics rather than true critical thinking skills.⁶

Recognizing the above limitations, many educators have called for changing to outcome-based, or competency-based, training (CBME). CBME targets attainment of skills in performing concrete critical clinical activities,⁸ such as identifying unstable patients, providing initial management, and obtaining help. To be successful, supervisors must directly observe trainees, assess demonstrated skills, and provide feedback about progress.

Unfortunately, this considerable investment of time and effort is often poorly compensated. Additionally, unanswered questions remain. For example, how will residency programs continue to challenge physicians deemed “competent” in a required skill? What happens when a trainee is deficient and not appropriately progressing in a required skill? Is flexible training time part of the future of medical education? While CBME appears to be a more effective method of education, questions like these must be addressed during implementation.

Beyond the fact that hours worked cannot be used as a surrogate for competency, excessive unregulated work hours can be detrimental to learners, their supervisors, and patients. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major change in medical education: duty hour limitations. The premise that sleep-deprived providers are more prone to error is well established. However, controversy remains as to whether these regulations translate into improved patient care and provider well-being. Studies published following the ACGME change demonstrate increasing burnout among physicians,^9-11 which has led some educators to explore the potential relationship between burnout and duty hour restrictions.

The recent “iCOMPARE” trial, which compared internal medicine (IM) residencies with “standard duty-hour” policies to those with “flexible” policies (that is, they did not specify limits on shift length or mandatory time off between shifts), supported a lack of correlation between hours worked and burnout.¹² Researchers administered the Maslach Burnout Inventory to all participants.¹³ While those in the “flexible hours” arm reported greater dissatisfaction with the effect of the program on their personal lives, both groups reported significant burnout, with interns recording high scores in emotional exhaustion (79% in flexible programs vs. 72% in standard), depersonalization (75% vs. 72%), and lack of personal accomplishment (71% vs. 69%).

Disturbingly, these scores were not restricted to interns but were present in all residents. The good news? Limiting duty hours does not cause burnout. On the other hand, it does not protect from burnout. Trainee burnout appears to transcend the issue of hours worked. Clearly, we need to address the systemic flaws in our work environments that contribute to this epidemic. Nationwide, educators and organizations are continuing to define causes of burnout and test interventions to improve wellness.

A final front of change in medical education worth mentioning is the use of the electronic medical record (EMR). While the EMR has improved many aspects of patient care, its implementation is associated with decreased time spent with patients and parallels the rise in burnout. Another unforeseen consequence has been its disruptive impact on medical student documentation. A national survey of clerkship directors found that, while 64% of programs allowed students to use the EMR, only two-thirds of those programs permitted students to document electronically.¹⁴

Many institutions limit student access because of either liability concerns or the fact that student notes cannot be used to support medical billing. Concerning workarounds among preceptors, such as logging in students under their own credentials to write notes, have been identified.¹⁵ Yet medical students need to learn how to document a clinical encounter and maintain medical records.^7,16 Authoring notes engages students, promotes a sense of patient ownership, and empowers them to feel like essential team members. Participating in the EMR also allows for critical feedback and skill development.

In 2016, the Society of Hospital Medicine joined several major internal medicine organizations in asking the federal government to reconsider guidelines prohibiting attendings from referring to medical student notes. In February 2018, the Centers for Medicare & Medicaid Services (CMS) revised its student documentation guidelines (see Box A), allowing teaching physicians to use all student documentation (not just Review of Systems, Family History, and Social History) for billable services.

While the guidelines officially went into effect in March 2018, many institutions are still fine-tuning their implementation, in part because of nonspecific policy language. For instance, if a student composes a note and a resident edits and signs it, can the attending physician simply cosign the resident note? Also, once a student has presented a case, can the attending see the patient and verify findings without the student present?

Despite the above challenges, the revision to CMS guidelines is a significant “win” and can potentially reduce the documentation burden on teaching physicians. With more oversight of their notes, the next generation of students will be encouraged to produce accurate, high-quality documentation.

In summary, these changes in the way we define competency, in duty hours, and in the use of the EMR demonstrate that medical education is continuously improving via robust critique and educator engagement in outcomes. We are fortunate to train in a system that respects the scientific method and utilizes data and critical events to drive important changes in practice. Understanding these changes might help hospitalists relate to the backgrounds and needs of learners. And who knows – maybe next time that intern will do a better job presenting!
 

Dr. Kwan is a hospitalist at the Veterans Affairs San Diego Healthcare System (VASDHS) and an associate professor at the University of California, San Diego, in the division of hospital medicine. He is the chair of the SHM Physicians in Training committee. Dr. Sebasky is an associate clinical professor at UCSD in the division of hospital medicine. Dr. Muchmore is a hematologist/oncologist and professor of clinical medicine in the department of medicine at UCSD and associate chief of staff for education at VASDHS.

References

1. Osler W. “The Hospital as a College.” In Aequanimitas. Osler W, Ed. (Philadelphia: P. Blakiston’s Son & Co., 1932).

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health Care System. (Washington: National Academies Press, 1999).

3. Ten Cate O. Competency-based postgraduate medical education: Past, present and future. GMS J Med Educ. 2017 Nov 15. doi: 10.3205/zma001146.

4. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician–educators. Acad Med. 2016;91(5):645-9.

5. 2016 NBME Clinical Clerkship Subject Examination Survey.

6. Mehta NB, Hull AL, Young JB, et al. Just imagine: New paradigms for medical education. Acad Med. 2013;88(10):1418-23.

7. Fazio SB, Ledford CH, Aronowitz PB, et al. Competency-based medical education in the internal medicine clerkship: A report from the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force. Acad Med. 2018;93(3):421-7.

8. Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007 Jun;82(6):542-7.

9. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open. 2017. doi: 10.1136/bmjopen-2016-015141.

10. Hall LH, Johnson J, Watt I, et al. Healthcare Staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE. 2016. doi: 10.1371/journal.pone.0159015.

11. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Gen Intern Med. 2017 Apr; 32(4):475-82.

12. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty hour flexibility trial in internal medicine. N Engl J Med. 2018 378:1494-508.

13. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. 3rd ed. (Palo Alto, CA: Consulting Psychologists Press, 1996).

14. Hammoud MM, Margo K, Christner JG, et al. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-24.

15. White J, Anthony D, WinklerPrins V, et al. Electronic medical records, medical students, and ambulatory family physicians: A multi-institution study. Acad Med. 2017;92(10):1485-90.

16. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310(21):2249-50.
 

Box A

“Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
 

 

It’s Monday morning, and your intern is presenting an overnight admission. Lost in the details of his disorganized introduction, your mind wanders. “Why doesn’t this intern know how to present? When I trained, all those admissions during long sleepless nights really taught me to do this right.” But can we equate hours worked with competency achieved? And if not, what is the alternative? This article introduces some major changes in medical education and their implications for hospitalists.

Most hospitalists trained in an educational system influenced by Sir William Osler. In the early 1900s, he introduced the natural method of teaching, positing that student exposure to patients and experience over time ensured that physicians in training would become competent doctors.¹ His influence led to the current structure of medical education, which includes conventional third-year clerkships and time-limited rotations (such as a 2-week nephrology block).

While familiarity may be comforting, there are signs our current model of medical education is inefficient, inadequate, and obsolete.

For one, the traditional system is failing to adequately prepare physicians to provide safe and complex care. Reports, such as the Institute of Medicine’s (IOM) “To Err is Human,”² describe a high rate of preventable errors, highlighting considerable room for improvement in training the next generation of physicians.^3,4

Meanwhile, trainees are still largely being deemed ready for the workforce by length of training completed (for example, completion of four-year medical school) rather than a skill set distinctly achieved. Our system leaves little flexibility to individualize learner goals, which is significant given some students and residents take shorter or longer periods of time to achieve proficiency. In addition, learner outcomes can be quite variable, as we have all experienced.

Even our methods of assessment may not adequately evaluate trainees’ skill sets. For example, most clerkships still rely heavily on the shelf exam⁵ as a surrogate for medical knowledge. As such, learners may conclude that testing performance trumps development of other professional skills.⁶ Efforts are being made to revamp evaluation systems to reflect mastery (such as Entrustable Professional Activities, or EPAs) toward competencies.⁷ Still, many institutions continue to rely on faculty evaluations that often reflect interpersonal dynamics rather than true critical thinking skills.⁶

Recognizing the above limitations, many educators have called for changing to outcome-based, or competency-based, training (CBME). CBME targets attainment of skills in performing concrete critical clinical activities,⁸ such as identifying unstable patients, providing initial management, and obtaining help. To be successful, supervisors must directly observe trainees, assess demonstrated skills, and provide feedback about progress.

Unfortunately, this considerable investment of time and effort is often poorly compensated. Additionally, unanswered questions remain. For example, how will residency programs continue to challenge physicians deemed “competent” in a required skill? What happens when a trainee is deficient and not appropriately progressing in a required skill? Is flexible training time part of the future of medical education? While CBME appears to be a more effective method of education, questions like these must be addressed during implementation.

Beyond the fact that hours worked cannot be used as a surrogate for competency, excessive unregulated work hours can be detrimental to learners, their supervisors, and patients. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major change in medical education: duty hour limitations. The premise that sleep-deprived providers are more prone to error is well established. However, controversy remains as to whether these regulations translate into improved patient care and provider well-being. Studies published following the ACGME change demonstrate increasing burnout among physicians,^9-11 which has led some educators to explore the potential relationship between burnout and duty hour restrictions.

The recent “iCOMPARE” trial, which compared internal medicine (IM) residencies with “standard duty-hour” policies to those with “flexible” policies (that is, they did not specify limits on shift length or mandatory time off between shifts), supported a lack of correlation between hours worked and burnout.¹² Researchers administered the Maslach Burnout Inventory to all participants.¹³ While those in the “flexible hours” arm reported greater dissatisfaction with the effect of the program on their personal lives, both groups reported significant burnout, with interns recording high scores in emotional exhaustion (79% in flexible programs vs. 72% in standard), depersonalization (75% vs. 72%), and lack of personal accomplishment (71% vs. 69%).

Disturbingly, these scores were not restricted to interns but were present in all residents. The good news? Limiting duty hours does not cause burnout. On the other hand, it does not protect from burnout. Trainee burnout appears to transcend the issue of hours worked. Clearly, we need to address the systemic flaws in our work environments that contribute to this epidemic. Nationwide, educators and organizations are continuing to define causes of burnout and test interventions to improve wellness.

A final front of change in medical education worth mentioning is the use of the electronic medical record (EMR). While the EMR has improved many aspects of patient care, its implementation is associated with decreased time spent with patients and parallels the rise in burnout. Another unforeseen consequence has been its disruptive impact on medical student documentation. A national survey of clerkship directors found that, while 64% of programs allowed students to use the EMR, only two-thirds of those programs permitted students to document electronically.¹⁴

Many institutions limit student access because of either liability concerns or the fact that student notes cannot be used to support medical billing. Concerning workarounds among preceptors, such as logging in students under their own credentials to write notes, have been identified.¹⁵ Yet medical students need to learn how to document a clinical encounter and maintain medical records.^7,16 Authoring notes engages students, promotes a sense of patient ownership, and empowers them to feel like essential team members. Participating in the EMR also allows for critical feedback and skill development.

In 2016, the Society of Hospital Medicine joined several major internal medicine organizations in asking the federal government to reconsider guidelines prohibiting attendings from referring to medical student notes. In February 2018, the Centers for Medicare & Medicaid Services (CMS) revised its student documentation guidelines (see Box A), allowing teaching physicians to use all student documentation (not just Review of Systems, Family History, and Social History) for billable services.

While the guidelines officially went into effect in March 2018, many institutions are still fine-tuning their implementation, in part because of nonspecific policy language. For instance, if a student composes a note and a resident edits and signs it, can the attending physician simply cosign the resident note? Also, once a student has presented a case, can the attending see the patient and verify findings without the student present?

Despite the above challenges, the revision to CMS guidelines is a significant “win” and can potentially reduce the documentation burden on teaching physicians. With more oversight of their notes, the next generation of students will be encouraged to produce accurate, high-quality documentation.

In summary, these changes in the way we define competency, in duty hours, and in the use of the EMR demonstrate that medical education is continuously improving via robust critique and educator engagement in outcomes. We are fortunate to train in a system that respects the scientific method and utilizes data and critical events to drive important changes in practice. Understanding these changes might help hospitalists relate to the backgrounds and needs of learners. And who knows – maybe next time that intern will do a better job presenting!
 

Dr. Kwan is a hospitalist at the Veterans Affairs San Diego Healthcare System (VASDHS) and an associate professor at the University of California, San Diego, in the division of hospital medicine. He is the chair of the SHM Physicians in Training committee. Dr. Sebasky is an associate clinical professor at UCSD in the division of hospital medicine. Dr. Muchmore is a hematologist/oncologist and professor of clinical medicine in the department of medicine at UCSD and associate chief of staff for education at VASDHS.

References

1. Osler W. “The Hospital as a College.” In Aequanimitas. Osler W, Ed. (Philadelphia: P. Blakiston’s Son & Co., 1932).

2. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health Care System. (Washington: National Academies Press, 1999).

3. Ten Cate O. Competency-based postgraduate medical education: Past, present and future. GMS J Med Educ. 2017 Nov 15. doi: 10.3205/zma001146.

4. Carraccio C, Englander R, Van Melle E, et al. Advancing competency-based medical education: A charter for clinician–educators. Acad Med. 2016;91(5):645-9.

5. 2016 NBME Clinical Clerkship Subject Examination Survey.

6. Mehta NB, Hull AL, Young JB, et al. Just imagine: New paradigms for medical education. Acad Med. 2013;88(10):1418-23.

7. Fazio SB, Ledford CH, Aronowitz PB, et al. Competency-based medical education in the internal medicine clerkship: A report from the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force. Acad Med. 2018;93(3):421-7.

8. Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007 Jun;82(6):542-7.

9. Dewa CS, Loong D, Bonato S, et al. The relationship between physician burnout and quality of healthcare in terms of safety and acceptability: A systematic review. BMJ Open. 2017. doi: 10.1136/bmjopen-2016-015141.

10. Hall LH, Johnson J, Watt I, et al. Healthcare Staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE. 2016. doi: 10.1371/journal.pone.0159015.

11. Salyers MP, Bonfils KA, Luther L, et al. The relationship between professional burnout and quality and safety in healthcare: A meta-analysis. Gen Intern Med. 2017 Apr; 32(4):475-82.

12. Desai SV, Asch DA, Bellini LM, et al. Education outcomes in a duty hour flexibility trial in internal medicine. N Engl J Med. 2018 378:1494-508.

13. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory manual. 3rd ed. (Palo Alto, CA: Consulting Psychologists Press, 1996).

14. Hammoud MM, Margo K, Christner JG, et al. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A national survey of clerkship directors. Teach Learn Med. 2012;24(3):219-24.

15. White J, Anthony D, WinklerPrins V, et al. Electronic medical records, medical students, and ambulatory family physicians: A multi-institution study. Acad Med. 2017;92(10):1485-90.

16. Pageler NM, Friedman CP, Longhurst CA. Refocusing medical education in the EMR era. JAMA 2013;310(21):2249-50.
 

Box A

“Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.”
 

 

With the heart of a child and the spirit of a warrior, Carl Bell always spoke his truth. And, he did so in his own inimitable way. Sporting his signature dark brown wide-brim leather cowboy hat or NMA (National Medical Association) baseball cap, aviator sunglasses, and accompanying Superman belt buckle, Carl Compton Bell, MD, – psychiatrist, researcher, mental health advocate, father, grandfather, friend, colleague, pioneer, and servant – was driven by a deep commitment to serve others.

As those who truly knew him can attest, it is not hyperbole to say that Carl Compton Bell was one of the most genuine, brilliant, and humble physicians of our professional community and time.

My collaboration and friendship began with Dr. Bell began during the summer of 2016 as I was preparing for the 2017 Washington Psychiatric Society’s (WPS) Presidential Symposium at Saint Elizabeths Hospital. As president of WPS, I had chosen gun violence as my topic and sought out Dr. Bell because of his work on the South Side of Chicago, where he had devoted himself, becoming an internationally known clinician, researcher, and mental health advocate for those personally affected by violence and trauma. He immediately accepted.

In his presentation, “Gun Violence, Urban Youth and Mental Illness,” he reviewed his research on the neurocognitive behavioral effects of prenatal exposure to alcohol and its relation to the neurodevelopmental dynamics of youth violence, intimate partner violence, and mass shootings. Dr. Bell suggested that the relationship between prenatal exposure to alcohol and the diagnosis of numerous psychiatric conditions had been underestimated in the medical community. He eventually summarized his work in Fetal Alcohol Exposure in the African-American Community, published by Third World Press (2018). This vital resource not only summarizes in plain language the scope of the problem of prenatal alcohol exposure but is a narrative of Carl Bell’s life journey.

After the symposium, he would send articles, while warning, “I can bombard you with stuff.” Sometimes we would not speak for weeks at a time while I digested the resources he had shared. However, whenever I picked up the phone to call and respond to what he had provided, he would answer the phone, “Yessssss?” – as if he were anticipating my call and was ready to address any queries or comments I might have. Even when he were about to board a plane or charting – after making rounds on his patients while listening to the music of James Brown – he would answer the phone, even if only to coordinate a more mutually convenient time to connect.

During the process of digesting the plethora of articles and resources he provided on prenatal fetal alcohol exposure, including the 1996 Institute of Medicine’s report and the American Medical Association’s 2017 resolution supporting the addition of adequate amounts of choline to prenatal vitamins, I found myself immersed in neuroscience topics, such as the role of neuronal acetylcholine receptor subunit alpha-7 in the formation of neurotransmitters, the strengthening of cell membranes, and the promotion of proper brain and spinal cord development. Dr. Bell spoke authoritatively about the neuroscience and the public health implications. One of his mantras was “Where is the data? You’ve got to have data.”

Courtesy Dr. Constance E. Dunlap

The information that he shared became the foundation of the action paper calling for the American Psychiatric Association (APA) to endorse the AMA’s resolution supporting the addition of adequate amounts (450 mg/d for pregnant women) of phosphatidylcholine to prenatal vitamins. The APA Assembly passed this action paper in May 2018.

He was also responsible for a second action paper, “Psychiatric Management of the Impact of Racism on Social and Clinical Events,” which passed at the same May 2018 assembly. Dr. Bell agreed to coauthor this paper, which was only fitting since the paper was a further elaboration of his efforts with the APA Caucus of Black Psychiatrists to implore the APA to acknowledge the deleterious effects of racism on both the victim and perpetrator.

While researching this topic, I had come across his 1980 article, Racism: A Symptom of the Narcissistic Personality Disorder (J Nat Med Assoc. 1980 Jul;72[7]:661-5), in which Dr. Bell applied psychoanalytic theory to posit that racism is one psychic derivative through which narcissism may manifest itself.

Although he was not formally trained as a psychoanalyst, he had benefited from strong psychoanalytic supervision at the Illinois State Psychiatric Institute, a training program of the University of Illinois at Chicago. He wrote confidently and clearly, applying self-psychology principles. He had the gravitas to write and speak about a range of topics, from neuroscience, psychotherapy, medical management of illness, and mental health advocacy. His 387-page curriculum vitae of 500+ articles, chapters, and books on mental health issues is a catalog of evidence that he had given thought to just about any topic along the spectrum of psychiatry and beyond.

In July 2018, after leaving a performance of “Hamilton” at the Kennedy Center, a lyric from the song “Non-Stop” stayed with me:

Why do you write like you’re running out of time?

(Why do you write like you’re running out of time?)

Write day and night like you’re running out of time?

The pace at which he read, wrote, lectured, researched, collaborated, and served on committees reminded me of the prodigious work of the former Secretary of the Treasury. When I shared this with Dr. Bell, he volunteered that he wrote to clear his mind. I suggested that, like other true writers, it seemed that he had to write. He did not disagree.

Courtesy Dr. Constance E. Dunlap

But, what was most meaningful about his productivity was his generosity of spirit. Any conversation was an opportunity for him to thoughtfully and respectfully share his knowledge. For example, once, we were discussing a clinical case that included the differential diagnosis of a patient, who happened to be African American, who was having auditory hallucinations. Dr. Bell might have been the first psychiatrist to alert the medical community about the misdiagnosis of schizophrenia among African Americans with bipolar disorder (J Nat Med Assoc. 1980 Feb 72[2]:141-5).

Contrary to my expectation that he was going to remind me of the tendency to misdiagnose, he instead offered, “You know, there are 40 reasons for auditory hallucinations.” Not what I had expected, yet, a response that reflected his continually giving nature and sharing of his abundance of gems. He was always teaching.

I later learned that his workday at Jackson Park Hospital usually ended at 2 p.m. He had treated patients, and supervised medical students and residents there for more than 40 years. The afternoons afforded him time to read, write, listen to music (Ella Fitzgerald), watch movies, and spend time with his adult children, to whom he was quite devoted. Dr. Bell was an avid martial artist and enjoyed sharing this practice with his son, William.

He was a longtime active member of the National Medical Association, recently receiving its prestigious Distinguished Service Award in Hawaii for his “exceptional work in medical service, medical research, and academic medicine.” It would be his last professional talk, though his delivery would belie his numbered days.

He was a former vice president of the Black Psychiatrists of America (BPA) and for 10 years had been the editor of the BPA Newsletter. Conversations were often peppered with anecdotes from time spent with other pioneering ancestors, such as Chester “Chet” Pierce, MD, Jeanne Spurlock, MD, Robert Phillips, MD, PhD, Charles Prudhomme, MD, Frances Cress Welsing, MD, and others. Dr. Bell was at the tail end of a generation of African American psychiatrists who had experienced firsthand the transition from segregation to federally mandated integration of our society.

Dr. Bell and his peers applied their education and training to improve clinical care for all, to decrease health inequities, and to eliminate disparities. It is evident that he loved his people and committed his life to addressing the needs of marginalized communities, those without the benefit of abundant resources, and those disproportionately affected by violence and trauma. As he stated in his last book, Fetal Alcohol Exposure in the African-American Community:

“I should add, my main concern is African American people living within the United States of America where in one community the rate of Fetal Alcohol Exposure is 388/1,000 people. ... However, this problem extends much further. Fetal Alcohol Exposure (FAE) is increasingly being found to (be) problematic in people of color around the world: Native Americans in Canada ... Aboriginal people in Australia ... and various tribes of people on the continent of Africa. ... Lastly, while the problem of Fetal Alcohol Exposure seems to be disproportionately affecting people of color, it also affects people who lack pigment in their skin. For example, FAE is a problem in Russia. From a public health perspective, so often people of color are like the proverbial “canary in a coal mine,” i.e., if there is poisonous gas in the coal mine, the canary will die first, warning the miners that they need to do something about it.”

Courtesy Dr. Constance E. Dunlap

However, it would be a profound mistake to conclude that his work was restricted to black and brown communities. Dr. Bell was a Distinguished Lifetime Fellow of the American Psychiatric Association and a Lifetime Fellow of the American College of Psychiatrists. He was a founding member of the board of directors of the National Commission on Correctional Health, and a member of prominent work groups of the National Institutes of Mental Health and the National Academy of Medicine (formerly the Institute of Medicine). And Dr. Bell’s mentees and students transcend generations, race, religions, professional disciplines, and national boundaries.

Because Dr. Bell was grounded and never forgot his roots, it was in these professional society circles that he ensured that clinicians with more privilege and limited or no exposure to communities of color were educated about the needs of those he treated. Without exposure to Carl Bell, it is likely that many of our psychiatric colleagues would remain unaware of both the brilliant dynamic resources and enormous challenges that are found in the black community and communities of color. By sharing his work with the house of medicine, he obviated the excuse of doing nothing because of ignorance.

Courtesy Dr. Constance E. Dunlap

I last saw Dr. Bell in San Francisco toward the end of the 2019 annual APA meeting. He had received the APA’s Adolf* Meyer Award for lifetime achievement. Afterward, I joined him for a dim sum lunch in Chinatown with two of his colleagues and Joseph Calhoun, his mentee in the APA’s Black Men in Psychiatry Early Pipeline Program. As we walked back to our respective hotels, we paused at what is now the Chinese Affirmative Action Center. We learned that this site had been the home of one of Dr. Bell’s former martial arts instructors. As Dr. Bell recounted his martial arts training, the reverence for his sensei was evident in his eyes.

When I reflect on how much I learned from and about Carl Bell in such a short period of time, I realize that he was one of those people who was so present and so astute that he allowed you to know him while he was giving.

So, how do we honor someone who gave so much of himself? When I now think of the lyric from “Hamilton” – “Why do you write like you’re running out of time?” – I realize that we get it twisted when we associate running out of time with our elders and their phase of life. It was not Carl Bell who was running out of time. He had been extraordinarily respectful of the space, time, and energy allotted to him in his lifetime. He would say, “People squander their personal resources.” He certainly had not squandered his.

As we reflect and mourn his passing, we will hear about his candor, authenticity, integrity, discipline, reliability, dedication, and serving spirit. This is called character.

Dr. Bell was beyond generous with his life, and it is going to take decades, if not more, for us to digest the compendium of knowledge that he left behind. I ask you: How will you use that knowledge to advance the causes he so diligently devoted his life to solving?

To Carl Compton Bell, I say, Well done. Thank you. And, rest now my dear brother.
 

Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is a Washington Psychiatric Society representative to the APA Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics.

*This column was updated 9/3/2019.

 

With the heart of a child and the spirit of a warrior, Carl Bell always spoke his truth. And, he did so in his own inimitable way. Sporting his signature dark brown wide-brim leather cowboy hat or NMA (National Medical Association) baseball cap, aviator sunglasses, and accompanying Superman belt buckle, Carl Compton Bell, MD, – psychiatrist, researcher, mental health advocate, father, grandfather, friend, colleague, pioneer, and servant – was driven by a deep commitment to serve others.

As those who truly knew him can attest, it is not hyperbole to say that Carl Compton Bell was one of the most genuine, brilliant, and humble physicians of our professional community and time.

My collaboration and friendship began with Dr. Bell began during the summer of 2016 as I was preparing for the 2017 Washington Psychiatric Society’s (WPS) Presidential Symposium at Saint Elizabeths Hospital. As president of WPS, I had chosen gun violence as my topic and sought out Dr. Bell because of his work on the South Side of Chicago, where he had devoted himself, becoming an internationally known clinician, researcher, and mental health advocate for those personally affected by violence and trauma. He immediately accepted.

In his presentation, “Gun Violence, Urban Youth and Mental Illness,” he reviewed his research on the neurocognitive behavioral effects of prenatal exposure to alcohol and its relation to the neurodevelopmental dynamics of youth violence, intimate partner violence, and mass shootings. Dr. Bell suggested that the relationship between prenatal exposure to alcohol and the diagnosis of numerous psychiatric conditions had been underestimated in the medical community. He eventually summarized his work in Fetal Alcohol Exposure in the African-American Community, published by Third World Press (2018). This vital resource not only summarizes in plain language the scope of the problem of prenatal alcohol exposure but is a narrative of Carl Bell’s life journey.

After the symposium, he would send articles, while warning, “I can bombard you with stuff.” Sometimes we would not speak for weeks at a time while I digested the resources he had shared. However, whenever I picked up the phone to call and respond to what he had provided, he would answer the phone, “Yessssss?” – as if he were anticipating my call and was ready to address any queries or comments I might have. Even when he were about to board a plane or charting – after making rounds on his patients while listening to the music of James Brown – he would answer the phone, even if only to coordinate a more mutually convenient time to connect.

During the process of digesting the plethora of articles and resources he provided on prenatal fetal alcohol exposure, including the 1996 Institute of Medicine’s report and the American Medical Association’s 2017 resolution supporting the addition of adequate amounts of choline to prenatal vitamins, I found myself immersed in neuroscience topics, such as the role of neuronal acetylcholine receptor subunit alpha-7 in the formation of neurotransmitters, the strengthening of cell membranes, and the promotion of proper brain and spinal cord development. Dr. Bell spoke authoritatively about the neuroscience and the public health implications. One of his mantras was “Where is the data? You’ve got to have data.”

Courtesy Dr. Constance E. Dunlap

The information that he shared became the foundation of the action paper calling for the American Psychiatric Association (APA) to endorse the AMA’s resolution supporting the addition of adequate amounts (450 mg/d for pregnant women) of phosphatidylcholine to prenatal vitamins. The APA Assembly passed this action paper in May 2018.

He was also responsible for a second action paper, “Psychiatric Management of the Impact of Racism on Social and Clinical Events,” which passed at the same May 2018 assembly. Dr. Bell agreed to coauthor this paper, which was only fitting since the paper was a further elaboration of his efforts with the APA Caucus of Black Psychiatrists to implore the APA to acknowledge the deleterious effects of racism on both the victim and perpetrator.

While researching this topic, I had come across his 1980 article, Racism: A Symptom of the Narcissistic Personality Disorder (J Nat Med Assoc. 1980 Jul;72[7]:661-5), in which Dr. Bell applied psychoanalytic theory to posit that racism is one psychic derivative through which narcissism may manifest itself.

Although he was not formally trained as a psychoanalyst, he had benefited from strong psychoanalytic supervision at the Illinois State Psychiatric Institute, a training program of the University of Illinois at Chicago. He wrote confidently and clearly, applying self-psychology principles. He had the gravitas to write and speak about a range of topics, from neuroscience, psychotherapy, medical management of illness, and mental health advocacy. His 387-page curriculum vitae of 500+ articles, chapters, and books on mental health issues is a catalog of evidence that he had given thought to just about any topic along the spectrum of psychiatry and beyond.

In July 2018, after leaving a performance of “Hamilton” at the Kennedy Center, a lyric from the song “Non-Stop” stayed with me:

Why do you write like you’re running out of time?

(Why do you write like you’re running out of time?)

Write day and night like you’re running out of time?

The pace at which he read, wrote, lectured, researched, collaborated, and served on committees reminded me of the prodigious work of the former Secretary of the Treasury. When I shared this with Dr. Bell, he volunteered that he wrote to clear his mind. I suggested that, like other true writers, it seemed that he had to write. He did not disagree.

Courtesy Dr. Constance E. Dunlap

But, what was most meaningful about his productivity was his generosity of spirit. Any conversation was an opportunity for him to thoughtfully and respectfully share his knowledge. For example, once, we were discussing a clinical case that included the differential diagnosis of a patient, who happened to be African American, who was having auditory hallucinations. Dr. Bell might have been the first psychiatrist to alert the medical community about the misdiagnosis of schizophrenia among African Americans with bipolar disorder (J Nat Med Assoc. 1980 Feb 72[2]:141-5).

Contrary to my expectation that he was going to remind me of the tendency to misdiagnose, he instead offered, “You know, there are 40 reasons for auditory hallucinations.” Not what I had expected, yet, a response that reflected his continually giving nature and sharing of his abundance of gems. He was always teaching.

I later learned that his workday at Jackson Park Hospital usually ended at 2 p.m. He had treated patients, and supervised medical students and residents there for more than 40 years. The afternoons afforded him time to read, write, listen to music (Ella Fitzgerald), watch movies, and spend time with his adult children, to whom he was quite devoted. Dr. Bell was an avid martial artist and enjoyed sharing this practice with his son, William.

He was a longtime active member of the National Medical Association, recently receiving its prestigious Distinguished Service Award in Hawaii for his “exceptional work in medical service, medical research, and academic medicine.” It would be his last professional talk, though his delivery would belie his numbered days.

He was a former vice president of the Black Psychiatrists of America (BPA) and for 10 years had been the editor of the BPA Newsletter. Conversations were often peppered with anecdotes from time spent with other pioneering ancestors, such as Chester “Chet” Pierce, MD, Jeanne Spurlock, MD, Robert Phillips, MD, PhD, Charles Prudhomme, MD, Frances Cress Welsing, MD, and others. Dr. Bell was at the tail end of a generation of African American psychiatrists who had experienced firsthand the transition from segregation to federally mandated integration of our society.

Dr. Bell and his peers applied their education and training to improve clinical care for all, to decrease health inequities, and to eliminate disparities. It is evident that he loved his people and committed his life to addressing the needs of marginalized communities, those without the benefit of abundant resources, and those disproportionately affected by violence and trauma. As he stated in his last book, Fetal Alcohol Exposure in the African-American Community:

“I should add, my main concern is African American people living within the United States of America where in one community the rate of Fetal Alcohol Exposure is 388/1,000 people. ... However, this problem extends much further. Fetal Alcohol Exposure (FAE) is increasingly being found to (be) problematic in people of color around the world: Native Americans in Canada ... Aboriginal people in Australia ... and various tribes of people on the continent of Africa. ... Lastly, while the problem of Fetal Alcohol Exposure seems to be disproportionately affecting people of color, it also affects people who lack pigment in their skin. For example, FAE is a problem in Russia. From a public health perspective, so often people of color are like the proverbial “canary in a coal mine,” i.e., if there is poisonous gas in the coal mine, the canary will die first, warning the miners that they need to do something about it.”

Courtesy Dr. Constance E. Dunlap

However, it would be a profound mistake to conclude that his work was restricted to black and brown communities. Dr. Bell was a Distinguished Lifetime Fellow of the American Psychiatric Association and a Lifetime Fellow of the American College of Psychiatrists. He was a founding member of the board of directors of the National Commission on Correctional Health, and a member of prominent work groups of the National Institutes of Mental Health and the National Academy of Medicine (formerly the Institute of Medicine). And Dr. Bell’s mentees and students transcend generations, race, religions, professional disciplines, and national boundaries.

Because Dr. Bell was grounded and never forgot his roots, it was in these professional society circles that he ensured that clinicians with more privilege and limited or no exposure to communities of color were educated about the needs of those he treated. Without exposure to Carl Bell, it is likely that many of our psychiatric colleagues would remain unaware of both the brilliant dynamic resources and enormous challenges that are found in the black community and communities of color. By sharing his work with the house of medicine, he obviated the excuse of doing nothing because of ignorance.

Courtesy Dr. Constance E. Dunlap

I last saw Dr. Bell in San Francisco toward the end of the 2019 annual APA meeting. He had received the APA’s Adolf* Meyer Award for lifetime achievement. Afterward, I joined him for a dim sum lunch in Chinatown with two of his colleagues and Joseph Calhoun, his mentee in the APA’s Black Men in Psychiatry Early Pipeline Program. As we walked back to our respective hotels, we paused at what is now the Chinese Affirmative Action Center. We learned that this site had been the home of one of Dr. Bell’s former martial arts instructors. As Dr. Bell recounted his martial arts training, the reverence for his sensei was evident in his eyes.

When I reflect on how much I learned from and about Carl Bell in such a short period of time, I realize that he was one of those people who was so present and so astute that he allowed you to know him while he was giving.

So, how do we honor someone who gave so much of himself? When I now think of the lyric from “Hamilton” – “Why do you write like you’re running out of time?” – I realize that we get it twisted when we associate running out of time with our elders and their phase of life. It was not Carl Bell who was running out of time. He had been extraordinarily respectful of the space, time, and energy allotted to him in his lifetime. He would say, “People squander their personal resources.” He certainly had not squandered his.

As we reflect and mourn his passing, we will hear about his candor, authenticity, integrity, discipline, reliability, dedication, and serving spirit. This is called character.

Dr. Bell was beyond generous with his life, and it is going to take decades, if not more, for us to digest the compendium of knowledge that he left behind. I ask you: How will you use that knowledge to advance the causes he so diligently devoted his life to solving?

To Carl Compton Bell, I say, Well done. Thank you. And, rest now my dear brother.
 

Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is a Washington Psychiatric Society representative to the APA Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics.

*This column was updated 9/3/2019.

 

With the heart of a child and the spirit of a warrior, Carl Bell always spoke his truth. And, he did so in his own inimitable way. Sporting his signature dark brown wide-brim leather cowboy hat or NMA (National Medical Association) baseball cap, aviator sunglasses, and accompanying Superman belt buckle, Carl Compton Bell, MD, – psychiatrist, researcher, mental health advocate, father, grandfather, friend, colleague, pioneer, and servant – was driven by a deep commitment to serve others.

As those who truly knew him can attest, it is not hyperbole to say that Carl Compton Bell was one of the most genuine, brilliant, and humble physicians of our professional community and time.

My collaboration and friendship began with Dr. Bell began during the summer of 2016 as I was preparing for the 2017 Washington Psychiatric Society’s (WPS) Presidential Symposium at Saint Elizabeths Hospital. As president of WPS, I had chosen gun violence as my topic and sought out Dr. Bell because of his work on the South Side of Chicago, where he had devoted himself, becoming an internationally known clinician, researcher, and mental health advocate for those personally affected by violence and trauma. He immediately accepted.

In his presentation, “Gun Violence, Urban Youth and Mental Illness,” he reviewed his research on the neurocognitive behavioral effects of prenatal exposure to alcohol and its relation to the neurodevelopmental dynamics of youth violence, intimate partner violence, and mass shootings. Dr. Bell suggested that the relationship between prenatal exposure to alcohol and the diagnosis of numerous psychiatric conditions had been underestimated in the medical community. He eventually summarized his work in Fetal Alcohol Exposure in the African-American Community, published by Third World Press (2018). This vital resource not only summarizes in plain language the scope of the problem of prenatal alcohol exposure but is a narrative of Carl Bell’s life journey.

After the symposium, he would send articles, while warning, “I can bombard you with stuff.” Sometimes we would not speak for weeks at a time while I digested the resources he had shared. However, whenever I picked up the phone to call and respond to what he had provided, he would answer the phone, “Yessssss?” – as if he were anticipating my call and was ready to address any queries or comments I might have. Even when he were about to board a plane or charting – after making rounds on his patients while listening to the music of James Brown – he would answer the phone, even if only to coordinate a more mutually convenient time to connect.

During the process of digesting the plethora of articles and resources he provided on prenatal fetal alcohol exposure, including the 1996 Institute of Medicine’s report and the American Medical Association’s 2017 resolution supporting the addition of adequate amounts of choline to prenatal vitamins, I found myself immersed in neuroscience topics, such as the role of neuronal acetylcholine receptor subunit alpha-7 in the formation of neurotransmitters, the strengthening of cell membranes, and the promotion of proper brain and spinal cord development. Dr. Bell spoke authoritatively about the neuroscience and the public health implications. One of his mantras was “Where is the data? You’ve got to have data.”

Courtesy Dr. Constance E. Dunlap

The information that he shared became the foundation of the action paper calling for the American Psychiatric Association (APA) to endorse the AMA’s resolution supporting the addition of adequate amounts (450 mg/d for pregnant women) of phosphatidylcholine to prenatal vitamins. The APA Assembly passed this action paper in May 2018.

He was also responsible for a second action paper, “Psychiatric Management of the Impact of Racism on Social and Clinical Events,” which passed at the same May 2018 assembly. Dr. Bell agreed to coauthor this paper, which was only fitting since the paper was a further elaboration of his efforts with the APA Caucus of Black Psychiatrists to implore the APA to acknowledge the deleterious effects of racism on both the victim and perpetrator.

While researching this topic, I had come across his 1980 article, Racism: A Symptom of the Narcissistic Personality Disorder (J Nat Med Assoc. 1980 Jul;72[7]:661-5), in which Dr. Bell applied psychoanalytic theory to posit that racism is one psychic derivative through which narcissism may manifest itself.

Although he was not formally trained as a psychoanalyst, he had benefited from strong psychoanalytic supervision at the Illinois State Psychiatric Institute, a training program of the University of Illinois at Chicago. He wrote confidently and clearly, applying self-psychology principles. He had the gravitas to write and speak about a range of topics, from neuroscience, psychotherapy, medical management of illness, and mental health advocacy. His 387-page curriculum vitae of 500+ articles, chapters, and books on mental health issues is a catalog of evidence that he had given thought to just about any topic along the spectrum of psychiatry and beyond.

In July 2018, after leaving a performance of “Hamilton” at the Kennedy Center, a lyric from the song “Non-Stop” stayed with me:

Why do you write like you’re running out of time?

(Why do you write like you’re running out of time?)

Write day and night like you’re running out of time?

The pace at which he read, wrote, lectured, researched, collaborated, and served on committees reminded me of the prodigious work of the former Secretary of the Treasury. When I shared this with Dr. Bell, he volunteered that he wrote to clear his mind. I suggested that, like other true writers, it seemed that he had to write. He did not disagree.

Courtesy Dr. Constance E. Dunlap

But, what was most meaningful about his productivity was his generosity of spirit. Any conversation was an opportunity for him to thoughtfully and respectfully share his knowledge. For example, once, we were discussing a clinical case that included the differential diagnosis of a patient, who happened to be African American, who was having auditory hallucinations. Dr. Bell might have been the first psychiatrist to alert the medical community about the misdiagnosis of schizophrenia among African Americans with bipolar disorder (J Nat Med Assoc. 1980 Feb 72[2]:141-5).

Contrary to my expectation that he was going to remind me of the tendency to misdiagnose, he instead offered, “You know, there are 40 reasons for auditory hallucinations.” Not what I had expected, yet, a response that reflected his continually giving nature and sharing of his abundance of gems. He was always teaching.

I later learned that his workday at Jackson Park Hospital usually ended at 2 p.m. He had treated patients, and supervised medical students and residents there for more than 40 years. The afternoons afforded him time to read, write, listen to music (Ella Fitzgerald), watch movies, and spend time with his adult children, to whom he was quite devoted. Dr. Bell was an avid martial artist and enjoyed sharing this practice with his son, William.

He was a longtime active member of the National Medical Association, recently receiving its prestigious Distinguished Service Award in Hawaii for his “exceptional work in medical service, medical research, and academic medicine.” It would be his last professional talk, though his delivery would belie his numbered days.

He was a former vice president of the Black Psychiatrists of America (BPA) and for 10 years had been the editor of the BPA Newsletter. Conversations were often peppered with anecdotes from time spent with other pioneering ancestors, such as Chester “Chet” Pierce, MD, Jeanne Spurlock, MD, Robert Phillips, MD, PhD, Charles Prudhomme, MD, Frances Cress Welsing, MD, and others. Dr. Bell was at the tail end of a generation of African American psychiatrists who had experienced firsthand the transition from segregation to federally mandated integration of our society.

Dr. Bell and his peers applied their education and training to improve clinical care for all, to decrease health inequities, and to eliminate disparities. It is evident that he loved his people and committed his life to addressing the needs of marginalized communities, those without the benefit of abundant resources, and those disproportionately affected by violence and trauma. As he stated in his last book, Fetal Alcohol Exposure in the African-American Community:

“I should add, my main concern is African American people living within the United States of America where in one community the rate of Fetal Alcohol Exposure is 388/1,000 people. ... However, this problem extends much further. Fetal Alcohol Exposure (FAE) is increasingly being found to (be) problematic in people of color around the world: Native Americans in Canada ... Aboriginal people in Australia ... and various tribes of people on the continent of Africa. ... Lastly, while the problem of Fetal Alcohol Exposure seems to be disproportionately affecting people of color, it also affects people who lack pigment in their skin. For example, FAE is a problem in Russia. From a public health perspective, so often people of color are like the proverbial “canary in a coal mine,” i.e., if there is poisonous gas in the coal mine, the canary will die first, warning the miners that they need to do something about it.”

Courtesy Dr. Constance E. Dunlap

However, it would be a profound mistake to conclude that his work was restricted to black and brown communities. Dr. Bell was a Distinguished Lifetime Fellow of the American Psychiatric Association and a Lifetime Fellow of the American College of Psychiatrists. He was a founding member of the board of directors of the National Commission on Correctional Health, and a member of prominent work groups of the National Institutes of Mental Health and the National Academy of Medicine (formerly the Institute of Medicine). And Dr. Bell’s mentees and students transcend generations, race, religions, professional disciplines, and national boundaries.

Because Dr. Bell was grounded and never forgot his roots, it was in these professional society circles that he ensured that clinicians with more privilege and limited or no exposure to communities of color were educated about the needs of those he treated. Without exposure to Carl Bell, it is likely that many of our psychiatric colleagues would remain unaware of both the brilliant dynamic resources and enormous challenges that are found in the black community and communities of color. By sharing his work with the house of medicine, he obviated the excuse of doing nothing because of ignorance.

Courtesy Dr. Constance E. Dunlap

I last saw Dr. Bell in San Francisco toward the end of the 2019 annual APA meeting. He had received the APA’s Adolf* Meyer Award for lifetime achievement. Afterward, I joined him for a dim sum lunch in Chinatown with two of his colleagues and Joseph Calhoun, his mentee in the APA’s Black Men in Psychiatry Early Pipeline Program. As we walked back to our respective hotels, we paused at what is now the Chinese Affirmative Action Center. We learned that this site had been the home of one of Dr. Bell’s former martial arts instructors. As Dr. Bell recounted his martial arts training, the reverence for his sensei was evident in his eyes.

When I reflect on how much I learned from and about Carl Bell in such a short period of time, I realize that he was one of those people who was so present and so astute that he allowed you to know him while he was giving.

So, how do we honor someone who gave so much of himself? When I now think of the lyric from “Hamilton” – “Why do you write like you’re running out of time?” – I realize that we get it twisted when we associate running out of time with our elders and their phase of life. It was not Carl Bell who was running out of time. He had been extraordinarily respectful of the space, time, and energy allotted to him in his lifetime. He would say, “People squander their personal resources.” He certainly had not squandered his.

As we reflect and mourn his passing, we will hear about his candor, authenticity, integrity, discipline, reliability, dedication, and serving spirit. This is called character.

Dr. Bell was beyond generous with his life, and it is going to take decades, if not more, for us to digest the compendium of knowledge that he left behind. I ask you: How will you use that knowledge to advance the causes he so diligently devoted his life to solving?

To Carl Compton Bell, I say, Well done. Thank you. And, rest now my dear brother.
 

Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is a Washington Psychiatric Society representative to the APA Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics.

*This column was updated 9/3/2019.

Carl C. Bell, MD, started his career by asking the hard questions that no one dared to ask. His curiosity, courage, and compassion for all communities would lead him to impact the world in ways that few psychiatrists could ever imagine.

His accomplishments were many and far-reaching, dating back over 4 decades of service and research. He was a prolific author and researcher, having written more than 400 books, chapters, and articles. His research covered a lot of ground, but four critical areas of focus were childhood trauma, violence prevention, criminal justice reform, and most recently, fetal alcohol spectrum disorders.

The word “visionary” is frequently overused. But when we apply it to Dr. Carl Bell, the word does not do him justice. If you take a closer look at all four of those areas, you can see a common thread: What are the elements of a society that can tear communities apart?

When I look at Dr. Bell’s research, I see a man with a dedicated vision to addressing each of those elements in systematic way, and a determination to bring the results of that research into his Southside Chicago community in numerous ways, including by serving as president and CEO of the Community Mental Health Council, and as director of the Institute for Juvenile Research at the University of Illinois at Chicago.

Dr. Bell was a leader for his patients as well as for black psychiatrists. He was a founding member of Black Psychiatrists of America and served as a mentor in some way to the vast majority of black psychiatrists currently practicing in the country. As a black male psychiatrist, I saw Dr. Bell as a source of inspiration in my career and the standard by which I measured myself. I’m not talking about awards or accomplishments, as Dr. Bell has countless accolades, including most recently, being presented this year with the American Psychiatric Association’s Adolph Meyer Award for Lifetime Achievement in Psychiatric Research and the National Medical Association’s Scroll of Merit. I am referring to Dr. Bell’s willingness to walk away from something he thought was wrong.

For every accolade he won or prestigious committee he served on, I would wager that he declined or stepped way from just as many. Dr. Bell’s character and vision for psychiatry in general, and the mental health of African American communities specifically, would not allow him to pay lip service to agendas that were self-serving, and did not push the field and communities forward.

During his service as an editorial advisory board member for Clinical Psychiatry News, Dr. Bell could always be relied upon to offer an insightful perspective to any discussion, ranging from violence prevention to the social determinants of health and their role in fetal alcohol spectrum disorders.

What I will remember most about Dr. Bell is his strong character. My guess is that he was never shy about stating the truth to a patient or a president of the United States. He possessed the intellect to back up any of his views while also having the humility of a dedicated community psychiatrist who worked for no other reason than to serve his patients.

When I first met Dr. Bell, he was giving a grand rounds at the George Washington University department of psychiatry. He was wearing a hat during the lecture and a belt with the Superman logo. I thought to myself, “Whoa, this is a different type of guy,” then I sat and listened to the talk, and was utterly astounded by his intellect, humor, honesty, and passion for his patients. I had never heard a psychiatrist speak with a combination of such command and approachability, and again, I thought to myself, “Whoa, this is a different type of guy.”

Little did I know that Dr. Bell and I would end up serving together on the editorial board of CPN. I loved seeing Dr. Bell, and catching up and gleaning from his wisdom. I was very humbled by how generous Dr. Bell was with his time and the extent to which he would make himself available as a mentor. During a CPN board meeting, we were trying to come up with a mantra that would capture the mission of the new MDedge Psychiatry website. Dr. Bell (in a hat, of course) let everyone else talk, and then, in a calm voice, said: “We ask the hard questions.” As editor in chief of MDedge Psychiatry, I knew this had to be the mantra. It was aspirational, gave us an identity, and held our feet to the fire – to always ask hard questions in the service of patients and readers. I looked forward to discussing the evolution of the site, seeing him at meetings and conferences, brainstorming the implications of new advances in the field, and simply walking down the street and laughing.

Those events will never occur again, because Carl left us on Thursday, Aug 1. We at MDedge Psychiatry are grieving the loss of a colleague and friend. Carl has left us with a legacy of work that we are still coming to appreciate. He left us with a mandate to pursue the truth and make an impact in our communities. He taught black psychiatrists what it meant to stand up unapologetically for your community and society. As I reflect on the scope of his life, I have one last hard question for Carl: “Why did you have to leave us so soon?”

 

Dr. Norris is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Dr. Norris also is host of the MDedge Psychcast.

Carl C. Bell, MD, started his career by asking the hard questions that no one dared to ask. His curiosity, courage, and compassion for all communities would lead him to impact the world in ways that few psychiatrists could ever imagine.

His accomplishments were many and far-reaching, dating back over 4 decades of service and research. He was a prolific author and researcher, having written more than 400 books, chapters, and articles. His research covered a lot of ground, but four critical areas of focus were childhood trauma, violence prevention, criminal justice reform, and most recently, fetal alcohol spectrum disorders.

The word “visionary” is frequently overused. But when we apply it to Dr. Carl Bell, the word does not do him justice. If you take a closer look at all four of those areas, you can see a common thread: What are the elements of a society that can tear communities apart?

When I look at Dr. Bell’s research, I see a man with a dedicated vision to addressing each of those elements in systematic way, and a determination to bring the results of that research into his Southside Chicago community in numerous ways, including by serving as president and CEO of the Community Mental Health Council, and as director of the Institute for Juvenile Research at the University of Illinois at Chicago.

Dr. Bell was a leader for his patients as well as for black psychiatrists. He was a founding member of Black Psychiatrists of America and served as a mentor in some way to the vast majority of black psychiatrists currently practicing in the country. As a black male psychiatrist, I saw Dr. Bell as a source of inspiration in my career and the standard by which I measured myself. I’m not talking about awards or accomplishments, as Dr. Bell has countless accolades, including most recently, being presented this year with the American Psychiatric Association’s Adolph Meyer Award for Lifetime Achievement in Psychiatric Research and the National Medical Association’s Scroll of Merit. I am referring to Dr. Bell’s willingness to walk away from something he thought was wrong.

For every accolade he won or prestigious committee he served on, I would wager that he declined or stepped way from just as many. Dr. Bell’s character and vision for psychiatry in general, and the mental health of African American communities specifically, would not allow him to pay lip service to agendas that were self-serving, and did not push the field and communities forward.

During his service as an editorial advisory board member for Clinical Psychiatry News, Dr. Bell could always be relied upon to offer an insightful perspective to any discussion, ranging from violence prevention to the social determinants of health and their role in fetal alcohol spectrum disorders.

What I will remember most about Dr. Bell is his strong character. My guess is that he was never shy about stating the truth to a patient or a president of the United States. He possessed the intellect to back up any of his views while also having the humility of a dedicated community psychiatrist who worked for no other reason than to serve his patients.

When I first met Dr. Bell, he was giving a grand rounds at the George Washington University department of psychiatry. He was wearing a hat during the lecture and a belt with the Superman logo. I thought to myself, “Whoa, this is a different type of guy,” then I sat and listened to the talk, and was utterly astounded by his intellect, humor, honesty, and passion for his patients. I had never heard a psychiatrist speak with a combination of such command and approachability, and again, I thought to myself, “Whoa, this is a different type of guy.”

Little did I know that Dr. Bell and I would end up serving together on the editorial board of CPN. I loved seeing Dr. Bell, and catching up and gleaning from his wisdom. I was very humbled by how generous Dr. Bell was with his time and the extent to which he would make himself available as a mentor. During a CPN board meeting, we were trying to come up with a mantra that would capture the mission of the new MDedge Psychiatry website. Dr. Bell (in a hat, of course) let everyone else talk, and then, in a calm voice, said: “We ask the hard questions.” As editor in chief of MDedge Psychiatry, I knew this had to be the mantra. It was aspirational, gave us an identity, and held our feet to the fire – to always ask hard questions in the service of patients and readers. I looked forward to discussing the evolution of the site, seeing him at meetings and conferences, brainstorming the implications of new advances in the field, and simply walking down the street and laughing.

Those events will never occur again, because Carl left us on Thursday, Aug 1. We at MDedge Psychiatry are grieving the loss of a colleague and friend. Carl has left us with a legacy of work that we are still coming to appreciate. He left us with a mandate to pursue the truth and make an impact in our communities. He taught black psychiatrists what it meant to stand up unapologetically for your community and society. As I reflect on the scope of his life, I have one last hard question for Carl: “Why did you have to leave us so soon?”

 

Dr. Norris is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Dr. Norris also is host of the MDedge Psychcast.

Carl C. Bell, MD, started his career by asking the hard questions that no one dared to ask. His curiosity, courage, and compassion for all communities would lead him to impact the world in ways that few psychiatrists could ever imagine.

His accomplishments were many and far-reaching, dating back over 4 decades of service and research. He was a prolific author and researcher, having written more than 400 books, chapters, and articles. His research covered a lot of ground, but four critical areas of focus were childhood trauma, violence prevention, criminal justice reform, and most recently, fetal alcohol spectrum disorders.

The word “visionary” is frequently overused. But when we apply it to Dr. Carl Bell, the word does not do him justice. If you take a closer look at all four of those areas, you can see a common thread: What are the elements of a society that can tear communities apart?

When I look at Dr. Bell’s research, I see a man with a dedicated vision to addressing each of those elements in systematic way, and a determination to bring the results of that research into his Southside Chicago community in numerous ways, including by serving as president and CEO of the Community Mental Health Council, and as director of the Institute for Juvenile Research at the University of Illinois at Chicago.

Dr. Bell was a leader for his patients as well as for black psychiatrists. He was a founding member of Black Psychiatrists of America and served as a mentor in some way to the vast majority of black psychiatrists currently practicing in the country. As a black male psychiatrist, I saw Dr. Bell as a source of inspiration in my career and the standard by which I measured myself. I’m not talking about awards or accomplishments, as Dr. Bell has countless accolades, including most recently, being presented this year with the American Psychiatric Association’s Adolph Meyer Award for Lifetime Achievement in Psychiatric Research and the National Medical Association’s Scroll of Merit. I am referring to Dr. Bell’s willingness to walk away from something he thought was wrong.

For every accolade he won or prestigious committee he served on, I would wager that he declined or stepped way from just as many. Dr. Bell’s character and vision for psychiatry in general, and the mental health of African American communities specifically, would not allow him to pay lip service to agendas that were self-serving, and did not push the field and communities forward.

During his service as an editorial advisory board member for Clinical Psychiatry News, Dr. Bell could always be relied upon to offer an insightful perspective to any discussion, ranging from violence prevention to the social determinants of health and their role in fetal alcohol spectrum disorders.

What I will remember most about Dr. Bell is his strong character. My guess is that he was never shy about stating the truth to a patient or a president of the United States. He possessed the intellect to back up any of his views while also having the humility of a dedicated community psychiatrist who worked for no other reason than to serve his patients.

When I first met Dr. Bell, he was giving a grand rounds at the George Washington University department of psychiatry. He was wearing a hat during the lecture and a belt with the Superman logo. I thought to myself, “Whoa, this is a different type of guy,” then I sat and listened to the talk, and was utterly astounded by his intellect, humor, honesty, and passion for his patients. I had never heard a psychiatrist speak with a combination of such command and approachability, and again, I thought to myself, “Whoa, this is a different type of guy.”

Little did I know that Dr. Bell and I would end up serving together on the editorial board of CPN. I loved seeing Dr. Bell, and catching up and gleaning from his wisdom. I was very humbled by how generous Dr. Bell was with his time and the extent to which he would make himself available as a mentor. During a CPN board meeting, we were trying to come up with a mantra that would capture the mission of the new MDedge Psychiatry website. Dr. Bell (in a hat, of course) let everyone else talk, and then, in a calm voice, said: “We ask the hard questions.” As editor in chief of MDedge Psychiatry, I knew this had to be the mantra. It was aspirational, gave us an identity, and held our feet to the fire – to always ask hard questions in the service of patients and readers. I looked forward to discussing the evolution of the site, seeing him at meetings and conferences, brainstorming the implications of new advances in the field, and simply walking down the street and laughing.

Those events will never occur again, because Carl left us on Thursday, Aug 1. We at MDedge Psychiatry are grieving the loss of a colleague and friend. Carl has left us with a legacy of work that we are still coming to appreciate. He left us with a mandate to pursue the truth and make an impact in our communities. He taught black psychiatrists what it meant to stand up unapologetically for your community and society. As I reflect on the scope of his life, I have one last hard question for Carl: “Why did you have to leave us so soon?”

 

Dr. Norris is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. He also serves as assistant dean of student affairs at the university, and medical director of psychiatric and behavioral sciences at GWU Hospital. Dr. Norris also is host of the MDedge Psychcast.

It was a simple message in the body of an email: “A strong voice in and for psychiatry is now silent.”

That is how I shared the news of the passing of Carl Compton Bell, MD, with the leadership of the American Psychiatric Association and what I think Carl would have approved be shared. Although he was a member of APA, he was never interested in the trappings of leadership there or any other organizations of which he was a longtime member, really. He preferred to “do the work” and was known to not suffer fools who were in it to promote themselves. He was always ready, willing, and able to offer guidance or assistance in your work and never failed to have an opinion on what else you needed to do. Some of my favorite memories of Carl are the talks he initiated at the drop of a hat where he “dropped some knowledge” about what he was doing or what you should be doing.

Upon hearing of his death, I described him to someone as fearless, unapologetic, smart, and ready to advocate for black people at the drop of one of the many hats he wore over the years. In fact, his decades of wardrobes is one the other things many of us will remember – the CMHC baseball cap with the “Stop Black on Black” crime T-shirt, the Obama cap paired with an assortment of message T-shirts (depending on what issue he was focused on at the time), and, most recently, the longer hair sticking out from under the wide brim leather cowboy hat with the highway patrol polarized sunglasses.

Whether at the podium presenting or standing in the back of the room, he was a presence, an obvious powerful force in that room. And whether it was the Surgeon General or an audience at the Carter Center, the message was consistent and powerful. An international researcher, clinician, teacher, and author of more than 500 books, chapters, and articles, he spent most of his career directly addressing issues of violence and HIV prevention, misdiagnosis of psychiatric disorders in African Americans, and the psychological effects on children exposed to violence.

Honoring the legacy of Carl Bell is about more than how we can all follow in his footsteps and more about being like him – unapologetically fearless and focused on improving the health, mental health, and overall well-being of black people. He was very clear that his talents, his skills, his focus – whether it was clinical care, training, or research – would be on black people, and he was often amused at the response, mostly from white people, when he stated clearly that this was his focus. He was often challenged by them, and his response as I frequently heard him say was: “I care about black people; I want to help black people.” I think he basically felt that, if it was good for black people, it would also benefit everyone else.

So, there’s a lesson for us as we heap on the well-deserved accolades on him and his life’s work, and reminisce about our personal encounters and experiences with him over the decades. As we reflect on what he meant to each of us as a friend, a colleague, and a history maker, I think the lesson is that if Carl were here today, he’d say: “OK, that’s all good, thank you for the nice words but what are you doing for black people today? What are you doing to improve their health and life condition today?” I think if we really want to honor his legacy and continue his work, we must be as fearless and focused as he was as we follow his lead and carry on with the work that promotes mental health in the black community. And when we are challenged for wanting to do this work, we must be just as unapologetic and thoughtful as he was, even channeling our own “Carl Bell” moment if needed. As a lifelong martial arts practitioner, I will end with this: “The bamboo which bends in the wind is stronger than the mighty oak which breaks in a storm.” Carl was the bamboo, and he’s with the Ancestors now, encouraging us to do the work and bend not break. Rest, my brother; job well done!

Dr. Stewart is immediate past president of the American Psychiatric Association.

It was a simple message in the body of an email: “A strong voice in and for psychiatry is now silent.”

That is how I shared the news of the passing of Carl Compton Bell, MD, with the leadership of the American Psychiatric Association and what I think Carl would have approved be shared. Although he was a member of APA, he was never interested in the trappings of leadership there or any other organizations of which he was a longtime member, really. He preferred to “do the work” and was known to not suffer fools who were in it to promote themselves. He was always ready, willing, and able to offer guidance or assistance in your work and never failed to have an opinion on what else you needed to do. Some of my favorite memories of Carl are the talks he initiated at the drop of a hat where he “dropped some knowledge” about what he was doing or what you should be doing.

Upon hearing of his death, I described him to someone as fearless, unapologetic, smart, and ready to advocate for black people at the drop of one of the many hats he wore over the years. In fact, his decades of wardrobes is one the other things many of us will remember – the CMHC baseball cap with the “Stop Black on Black” crime T-shirt, the Obama cap paired with an assortment of message T-shirts (depending on what issue he was focused on at the time), and, most recently, the longer hair sticking out from under the wide brim leather cowboy hat with the highway patrol polarized sunglasses.

Whether at the podium presenting or standing in the back of the room, he was a presence, an obvious powerful force in that room. And whether it was the Surgeon General or an audience at the Carter Center, the message was consistent and powerful. An international researcher, clinician, teacher, and author of more than 500 books, chapters, and articles, he spent most of his career directly addressing issues of violence and HIV prevention, misdiagnosis of psychiatric disorders in African Americans, and the psychological effects on children exposed to violence.

Honoring the legacy of Carl Bell is about more than how we can all follow in his footsteps and more about being like him – unapologetically fearless and focused on improving the health, mental health, and overall well-being of black people. He was very clear that his talents, his skills, his focus – whether it was clinical care, training, or research – would be on black people, and he was often amused at the response, mostly from white people, when he stated clearly that this was his focus. He was often challenged by them, and his response as I frequently heard him say was: “I care about black people; I want to help black people.” I think he basically felt that, if it was good for black people, it would also benefit everyone else.

So, there’s a lesson for us as we heap on the well-deserved accolades on him and his life’s work, and reminisce about our personal encounters and experiences with him over the decades. As we reflect on what he meant to each of us as a friend, a colleague, and a history maker, I think the lesson is that if Carl were here today, he’d say: “OK, that’s all good, thank you for the nice words but what are you doing for black people today? What are you doing to improve their health and life condition today?” I think if we really want to honor his legacy and continue his work, we must be as fearless and focused as he was as we follow his lead and carry on with the work that promotes mental health in the black community. And when we are challenged for wanting to do this work, we must be just as unapologetic and thoughtful as he was, even channeling our own “Carl Bell” moment if needed. As a lifelong martial arts practitioner, I will end with this: “The bamboo which bends in the wind is stronger than the mighty oak which breaks in a storm.” Carl was the bamboo, and he’s with the Ancestors now, encouraging us to do the work and bend not break. Rest, my brother; job well done!

Dr. Stewart is immediate past president of the American Psychiatric Association.

It was a simple message in the body of an email: “A strong voice in and for psychiatry is now silent.”

That is how I shared the news of the passing of Carl Compton Bell, MD, with the leadership of the American Psychiatric Association and what I think Carl would have approved be shared. Although he was a member of APA, he was never interested in the trappings of leadership there or any other organizations of which he was a longtime member, really. He preferred to “do the work” and was known to not suffer fools who were in it to promote themselves. He was always ready, willing, and able to offer guidance or assistance in your work and never failed to have an opinion on what else you needed to do. Some of my favorite memories of Carl are the talks he initiated at the drop of a hat where he “dropped some knowledge” about what he was doing or what you should be doing.

Upon hearing of his death, I described him to someone as fearless, unapologetic, smart, and ready to advocate for black people at the drop of one of the many hats he wore over the years. In fact, his decades of wardrobes is one the other things many of us will remember – the CMHC baseball cap with the “Stop Black on Black” crime T-shirt, the Obama cap paired with an assortment of message T-shirts (depending on what issue he was focused on at the time), and, most recently, the longer hair sticking out from under the wide brim leather cowboy hat with the highway patrol polarized sunglasses.

Whether at the podium presenting or standing in the back of the room, he was a presence, an obvious powerful force in that room. And whether it was the Surgeon General or an audience at the Carter Center, the message was consistent and powerful. An international researcher, clinician, teacher, and author of more than 500 books, chapters, and articles, he spent most of his career directly addressing issues of violence and HIV prevention, misdiagnosis of psychiatric disorders in African Americans, and the psychological effects on children exposed to violence.

Honoring the legacy of Carl Bell is about more than how we can all follow in his footsteps and more about being like him – unapologetically fearless and focused on improving the health, mental health, and overall well-being of black people. He was very clear that his talents, his skills, his focus – whether it was clinical care, training, or research – would be on black people, and he was often amused at the response, mostly from white people, when he stated clearly that this was his focus. He was often challenged by them, and his response as I frequently heard him say was: “I care about black people; I want to help black people.” I think he basically felt that, if it was good for black people, it would also benefit everyone else.

So, there’s a lesson for us as we heap on the well-deserved accolades on him and his life’s work, and reminisce about our personal encounters and experiences with him over the decades. As we reflect on what he meant to each of us as a friend, a colleague, and a history maker, I think the lesson is that if Carl were here today, he’d say: “OK, that’s all good, thank you for the nice words but what are you doing for black people today? What are you doing to improve their health and life condition today?” I think if we really want to honor his legacy and continue his work, we must be as fearless and focused as he was as we follow his lead and carry on with the work that promotes mental health in the black community. And when we are challenged for wanting to do this work, we must be just as unapologetic and thoughtful as he was, even channeling our own “Carl Bell” moment if needed. As a lifelong martial arts practitioner, I will end with this: “The bamboo which bends in the wind is stronger than the mighty oak which breaks in a storm.” Carl was the bamboo, and he’s with the Ancestors now, encouraging us to do the work and bend not break. Rest, my brother; job well done!

Dr. Stewart is immediate past president of the American Psychiatric Association.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

 

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

 

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Lori J. Heim, MD, FAAFP, a hospitalist in practice at Scotland Memorial Hospital in Laurinburg, N.C., for the past 10 years, recalls when she first decided to pursue hospital medicine as a career. As a family physician in private practice who admitted patients to the local hospital in Pinehurst, N.C., and even followed them into the ICU, she needed a more flexible schedule when she became president-elect of the American Academy of Family Physicians (AAFP).

“My local hospital told me they had a policy against hiring family physicians as hospitalists. They didn’t consider us qualified,” Dr. Heim said. “I was incredulous when I first heard that because I already had full admitting privileges at the hospital. It made no sense, since they allowed me to manage my patients in the ICU.”

Then an opportunity opened at Scotland Memorial, located an hour away. “That has been a fabulous experience for me,” she said. The transition was relatively easy, following more than 2 decades of office practice. Dr. Heim’s hospitalist group now includes eight full-time clinicians who have a mix of family medicine and internal medicine backgrounds.

“I’ve never felt anything other than collegial support here. We go to the ER to evaluate patients and decide whether to admit them, and we do a lot of medical procedures. I’m not practicing pediatrics currently, but I have no problem conducting a gynecological exam. I think my experience in family medicine and primary care has been an asset,” Dr. Heim said. “I’m not sure I would be a hospitalist today if I had not been elected president of AAFP, but it was fortuitous.”

Respect for HTFMs is growing

Hospitalists trained in family medicine (HTFM) are a small but important segment of this field and of the membership of the Society of Hospital Medicine. The board specialties of physicians who work in the hospital are not always broken out in existing databases, but HTFMs are believed to represent about 8% of SHM members, and somewhere around 10%-15% of the total hospitalist workforce. According to SHM’s 2018 State of Hospital Medicine Report, 65% of hospital medicine groups employed at least one family medicine–trained provider in their group.¹

SHM’s Special Interest Group (SIG) for HTFMs reports to the society’s Board of Directors. The American Academy of Family Medicine, with 131,400 members, also has a Member Interest Group (MIG) for HTFMs. When AAFP recently surveyed its members to identify their primary patient care practice location, only 4% named the hospital (not including the emergency department), while 3% said the hospital emergency department.²

Among 32,450 adult primary care-trained hospitalists surveyed for the June 2016 AAMC In Brief of the American Association of Medical Colleges, 81.9% of the hospitalists identified internal medicine as their specialty, while 5.2% identified themselves as family physicians.³ A 2014 Medical Group Management Association survey, which reported data for 4,200 hospitalists working in community hospitals, found that 82% were internal medicine trained, versus 10% in family medicine and 7% in pediatrics.

Family medicine hospitalists may be more common in rural areas or in small hospitals – where a clinician is often expected to wear more hats, said hospitalist David Goldstein, MD, FHM, assistant director of the family medicine residency program at Natividad Medical Center, Salinas, Calif., and cochair of SHM’s family medicine SIG. “In a smaller hospital, if there’s not sufficient volume to support full-time pediatric and adult hospital medicine services, a family medicine hospitalist might do both – and even help staff the ICU.”

A decade or so ago, much of the professional literature about the role of HTFMs suggested that some had experienced a lack of respect or of equal job opportunities, while others faced pay differentials.^3-5 Since then, the field of hospital medicine has come a long way toward recognizing their contributions, although there are still hurdles to overcome, mainly involving issues of credentialing, to allow HTFMs to play equal roles in the hospital, the ICU, or in residency training. The SHM 2018 State of Hospital Medicine Report reveals that HTFMs actually made slightly higher salaries on average than their internist colleagues, $301,833 versus $300,030.

Prior to the advent of hospital medicine, both family medicine and internal medicine physicians practiced in much the same way in their medical offices, and visited their patients in the hospital, said Claudia Geyer, MD, SFHM, system chief of hospital medicine at Central Maine Healthcare in Lewiston. She is trained and boarded in both family and internal medicine. “When hospital medicine launched, its heavy academic emphasis on internists led to underrecognition of the continued contributions of family medicine. Family physicians never left the hospital setting and – in certain locales – were the predominant hospitalists. We just waited for the recognition to catch up with the reality,” Dr. Geyer said.

“I don’t feel family medicine for hospitalists is nearly the stepchild of internal medicine that it was when I first started,” Dr. Heim said. “In my multihospital hospitalist group, I haven’t seen anything to suggest that they treat family medicine hospitalists as second class.” The demand for hospitalists is greater than internists can fill, while clearly the public is not concerned about these distinctions, she said.

Whether clinicians are board certified in family medicine or internal medicine may be less important to their skills for practicing in the hospital than which residency program they completed, what emphasis it placed on working in the hospital or ICU, electives completed, and other past experience. “Some family medicine residencies offer more or less hospital experience,” Dr. Heim said.

Jasen Gundersen, MD, MBA, CPE, SFHM, president of acute and post-acute services for the national hospital services company TeamHealth, agreed that there has been dramatic improvement in the status of HTFMs. He is one, and still practices as a hospitalist at Boca Raton (Fla.) Regional Hospital when administrative responsibilities permit.

TeamHealth has long been open to family medicine doctors, Dr. Gundersen added, although some of the medical staff at hospitals that contract with TeamHealth have issues with it. “We will talk to them about it,” he said. “We hire hospitalists who can do the work, and we evaluate them based on their background and skill set, where they’ve practiced and for how long. We want people who are experienced and good at managing hospitalized patients. For new residency grads, we look at their electives and the focus of their training.”

 

What is home for HTFMs?

Where are HTFMs most likely to find their professional home? “That’s hard to answer,” said Patricia Seymour, MD, FHM, FAAFP, an academic hospitalist at the University of Massachusetts-Worcester. “In the last 4-5 years, SHM has worked very hard to create a space for HTFMs. AAFP has a hospital medicine track at their annual meeting, and that’s a good thing. But they also need to protect family physicians’ right to practice in any setting they choose. For those pursuing hospital medicine, there’s a different career trajectory, different CME needs, and different recertification needs.”

Dr. Seymour is the executive cochair of SHM’s family medicine SIG and serves as interim chief of a family medicine hospitalist group that provides inpatient training for a family practice residency, where up to a third of the 12 residents each year go on to pursue hospital medicine as a career. “We have the second-oldest family medicine–specific hospitalist group in the country, so our residency training has an emphasis on hospital medicine,” she explained.

“Because I’m a practicing hospitalist, the residents come to me seeking advice. I appreciate the training I received as a family physician in communication science, palliative care, geriatrics, family systems theory, and public health. I wouldn’t have done it any other way, and that’s how I counsel our students and residents,” she said. Others suggest that the generalist training and diverse experiences of family medicine can be a gift for a doctor who later chooses hospital medicine.

AAFP is a large umbrella organization and the majority of its members practice primary care, Dr. Heim said. “I don’t know the percentage of HTFMs who are members of AAFP. Some no doubt belong to both AAFP and SHM.” Even though both groups have recognized this important subset of their members who chose the field of hospital medicine and its status as a career track, it can be a stretch for family medicine to embrace hospitalists.

“It inherently goes against our training, which is to work in outpatient, inpatient, obstetric, pediatric, and adult settings,” Dr. Heim said. “It’s difficult to reconcile giving up a big part of what defined your training – that range of settings. I remember feeling like I should apologize to other family medicine doctors for choosing this path.”

Credentialing opportunities and barriers

For the diverse group of practicing HTFMs, credentialing and scope of practice represent their biggest current issues. A designation of Focused Practice in Hospital Medicine (FPHM) has been offered jointly since 2010 by the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM), although their specific requirements vary.

Eligible hospitalist candidates for the focused practice exam must have an unrestricted medical license, maintenance of current primary certification, and verification of three years of unsupervised hospital medicine practice experience. ABIM views FPHM not as a subspecialty, but as a variation of internal medicine certification, identifying diplomates who are board-certified in internal medicine with a hospital medicine specialization. They do not have to take the general internal medicine recertification exam if they qualify for FPHM.

ABFM-certified family physicians who work primarily in a hospital setting can take the same test for FPHM, with the same eligibility requirements. But ABFM does not consider focused practice a subspecialty, or the Certificate of Added Qualifications in Family Medicine as sufficient for board certification. That means family physicians also need to take its general board exam in order to maintain their ABFM board certification.

ABFM’s decision not to accept the focused practice designation as sufficient for boarding was disappointing to a lot of hospitalists, said Laura “Nell” Hodo, MD, FAAFP, chair of AAFP’s hospital medicine MIG, and a pediatric academic hospitalist at Icahn School of Medicine at Mount Sinai, New York. “Many family physicians practice hospital medicine exclusively and would prefer to take one boarding exam instead of two, and not have to do CME and board review in areas where we don’t practice anymore,” Dr. Hodo said, adding that she hopes that this decision could be revisited in the future.

A number of 1-year hospital medicine fellowships across the country provide additional training opportunities for both family practice and internal medicine residency graduates. These fellowships do not offer board certification or designated specialty credentialing for hospitalists and are not recognized by the American College of Graduate Medical Education (ACGME), which sets standards for residency and fellowship training. “But they reflect a need and an interest in optimizing the knowledge of hospital medicine and developing the specific skills needed to practice it well,” Dr. Geyer noted.

She directs a program for one to three fellows per year out of the Central Maine Family Medicine Residency program and Central Maine Medical Center in Lewiston, and is now recruiting her tenth class. At least 13 other hospital medicine fellowships, out of about 40 nationwide, are family medicine based. “We rely heavily on the Core Competencies in Hospital Medicine developed by SHM, which emphasize clinical conditions, medical procedures, and health care systems. Gaining fluency in the latter is really what makes hospital medicine unique,” Dr. Geyer said.

Often residency graduates seeking work in hospital medicine are insufficiently prepared for hospital billing and coding, enacting safe transitions of care, providing palliative care, and understanding how to impact their health care systems for quality improvement, patient safety and the like, she added.

Dr. Geyer said her fellowship does not mean just being a poorly paid hospitalist for a year. “The fellows are clearly trainees, getting the full benefit of our supervision and supplemental training focused on enhanced clinical and procedural exposure, but also on academics, quality improvement, leadership, and efficiency,” she said. “All of our fellows join SHM, go to the Annual Conference, propose case studies, do longitudinal quality or safety projects, and learn the other aspects of hospital medicine not well-taught in residency. We train them to be highly functional hospitalists right out of the gate.”

Until recently, another barrier for HTFMs was their ability to be on the faculty of internal medicine residency programs. Previous language from ACGME indicated that family medicine-trained physicians could not serve as faculty for these programs, Dr. Goldstein said. SHM has lobbied ACGME to change that rule, which could enable family medicine hospitalists who had achieved FPHM designation to be attendings and to teach internal medicine residents.
 

 

Needed in critical care – but not credentialed

One of the biggest frustrations for family medicine hospitalists is clarifying their role in the ICU. SHM’s Education Committee recently surveyed hospitalist members who practice in the ICU, finding that at least half felt obliged to practice beyond their scope, 90 percent occasionally perceived insufficient support from intensivists, and two-thirds reported moderate difficulty transferring patients to higher levels of intensive care.⁷ The respondents overwhelmingly indicated that they wanted more training and education in critical care medicine.

“I want to highlight the fact that in some settings family physicians are the sole providers of critical care,” Dr. Goldstein said. Meanwhile, the standards of the Leapfrog Group, a coalition of health care purchasers, call for ICUs to be staffed by physicians certified in critical care, even though there is a growing shortage of credentialed intensivists to treat an increasing number of older, sicker, critically ill patients.

Some internal medicine physicians don’t want to have anything to do with the ICU because of the medical and legal risks, said David Aymond, MD, a family physician and hospitalist at Byrd Regional Hospital in Leesville, La. “There’s a bunch of sick people in the ICU, and when some doctors like me started doing critical care, we realized we liked it. Depending on your locale, if you are doing hospital medicine, critically ill patients are going to fall in your lap,” he said. “But if you don’t have the skills, that could lead to poor outcomes and unnecessary transfers.”

Dr. Aymond started his career in family medicine. “When I got into residency, I saw how much critical care was needed in rural communities. I decided I would learn everything I could about it. I did a hospital medicine fellowship at the University of Alabama, which included considerable involvement in the ICU. When I went to Byrd Regional, a 60-bed facility with eight ICU beds, we did all of the critical care, and word started to spread in the community. My hospitalist partner and I are now on call 24/7 alternating weeks, doing the majority of the critical care and taking care of anything that goes on in an ICU at a larger center, although we often lack access to consultation services,” he explained.

“We needed to get the attention of the Society of Critical Care Medicine (SCCM) to communicate the scope of this problem. These doctors are doing critical care but there is no official medical training or recognition for them. So they’re legally out on a limb, even though often they are literally the only person available to do it,” Dr. Aymond said. “Certainly there’s a skills gap between HTFMs and board-certified intensivists, but some of that gap has to do with the volume of patients they have seen in the ICU and their comfort level,” he said.

SHM is pursuing initiatives to help address this gap, including collaborating with SCCM on developing a rigorous critical care training curriculum for internal medicine and family medicine hospitalists, with coursework drawn from existing sources, said Eric Siegal, MD, SFHM, a critical care physician in Milwaukee. “It doesn’t replace a 2-year critical care fellowship, but it will be a lot more than what’s currently out there for the nonintensivist who practices in the ICU.” SCCM has approved moving forward with the advanced training curriculum, he said.

Another priority is to try to create a pathway that could permit family medicine–trained hospitalists to apply for existing critical care fellowships, as internal medicine doctors are now able to do. SHM has lobbied ABFM to create a pathway to subspecialty certification in critical care medicine, similar to those that exist for internists and emergency physicians, Dr. Goldstein said, adding that ACGME, which controls access to fellowships, will be the next step. Dr. Aymond expects that there will be a lot of hoops to jump through.

“David Aymond is an exceptional hospitalist,” Dr. Siegal added. “He thinks and talks like an intensivist, but it took concerted and self-directed effort for him to get there. Family practitioners are a significant part of the rural critical care workforce, but their training generally does not adequately prepare them for this role – unless they have made a conscious effort to pursue additional training,” he said.

“My message to family practitioners is not that they’re not good enough to do this, but rather that they are being asked to do something they weren’t trained for. How can we help them do it well?”

References

1. Society of Hospital Medicine (SHM) Practice Analysis Committee. 2018 State of Hospital Medicine Report; Oct 2018.

2. American Academy of Family Physicians Member Census, Dec 31, 2017.

3. Jones KC et al. Hospitalists: A growing part of the primary care workforce. AAMC Analysis in Brief; June 2016; 16(5):1.

4. Berczuk C. Uniquely positioned. The Hospitalist; July 2009.

5. Iqbal Y. Family medicine hospitalists: Separate and unequal? Today’s Hospitalist; May 2007.

6. Kinnan JP. The family way. The Hospitalist; Nov 2007.

7. Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

 

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Besides getting to talk to my Dad, the occasional patient visit there is a reminder of the limits of being a physician, and of our own lives. If nothing else it helps keep a perspective on those things, such as family and health, that are truly important.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Besides getting to talk to my Dad, the occasional patient visit there is a reminder of the limits of being a physician, and of our own lives. If nothing else it helps keep a perspective on those things, such as family and health, that are truly important.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

 

Around once a month I go to the cemetery to visit my Dad. Although this was difficult 6 years ago when I started, it’s become easier thanks to that great healer, time.

germi_p/Thinkstock

His grave is a short distance from the parking spot, so I have to walk past a number of others to get there. As a result you see these change over time.

A few times in the last several years I’ve noticed a new grave marker that, to my surprise, has the name of one of my (former) patients on it. Granted, a lot of my practice is the above-75 crowd, and they wouldn’t be coming to me if they didn’t have health issues.

But still, it jolts me a bit when it happens. I may not have thought about them for a while, but suddenly I see the marker and realize why that person hadn’t been in recently. I can usually picture them, too, and remember something they may have said that concerned me or just made me laugh.

Obviously, regardless of age we all end up there, and I certainly don’t consider this a personal medical failing on my part. It’s the nature of life on Earth, no matter how good a job we do as physicians.

But it still surprises me. If it was a patient I have fond memories of, I’ll often stop and say a few words to them, too. To date no one has answered, but I suspect there’s something therapeutic for me in doing so. The cemetery is generally peaceful, and certainly not a place where I feel rushed.

Besides getting to talk to my Dad, the occasional patient visit there is a reminder of the limits of being a physician, and of our own lives. If nothing else it helps keep a perspective on those things, such as family and health, that are truly important.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

There is probably no area where human contact is more important than in the area of counseling and psychotherapy. Or so most of us have thought. It turns out that, even in behavioral medicine, technology has made fantastic inroads in helping patients achieve real improvement in troublesome behavioral symptoms. There is good evidence that digital interfaces for cognitive behavioral therapy (CBT) can help in the treatment of anxiety and depression. We will not go over that evidence in this column, other than to say that the evidence is there, but rather we will review some of the best apps that those of us in primary care can utilize in the care of our patients. It is our opinion that these apps are best used in conjunction with our care to supplement the counseling we are giving our patients in the office. Many of the apps listed may be used for both anxiety and depression, as well as in areas related to problem solving, self-esteem, anger management, creating lifestyle changes, and coping with uncertainty.

MoodKit

MoodKit is a CBT app with four main tools: a collection of activities focused on coping self-efficacy (a person’s belief in success in specific situations) that includes individual productivity, social relationships, physical activity, and healthy habits; a thought checker; mood tracker; and journal. MoodKit is accessed in an unstructured way and can be used as an unguided self-help app. It is useful in patient interactions to access interventions in areas such as social engagement and options for choosing a healthy lifestyle. It is available in Apple’s App Store, and it costs $4.99.

Moodnotes

Based on CBT and positive psychology, Moodnotes assists in recognizing and learning about “traps” in thinking, as well as emphasizing healthier thinking habits. Traps in thinking include “catastrophic thinking” where patients with depression may think that a small error or behavioral indiscretion may lead to a consequence that far exceeds what is likely, or “mind-reading” where a person assumes that others are critical of them without actually having evidence that this is the case. Moodnotes tracks mood over a period of time while identifying factors that influence it. It is helpful in between visits to aid clinicians in gaining perspective on mood patterns. It is available in the App Store; it costs $4.99.

MoodMission

This app recommends strategies based in CBT after input of low moods or feelings of anxiety. MoodMission provides five “missions” to engage in that promote confidence in handling stressors and promotes coping self-efficacy. The app learns what style works best and tailors techniques according to when a patient uses it most frequently. Rewards in the app are used to promote motivation and to increase pleasure and self-confidence. It is useful for patients who could use a lift in mood or decrease in symptoms of anxiety and depression. It available in the App Store and Google Play, and it’s free.

 

What’s Up

In line with its development based on principles from CBT and Acceptance and Commitment Therapy (ACT), What’s Up identifies common negative thinking patterns and methods to overcome them with useful metaphors, a catastrophe scale, grounding techniques, and breathing exercises. What’s Up syncs data across multiple devices and uses a unique passcode to protect this information. One of the abilities that separates it from other apps is that it can become active in forums where people discuss similar feelings and strategies that have been useful for them. It is available in the App Store and Google Play, and it’s free.

Moodpath

Moodpath uses daily screenings to create better understanding of thoughts, feelings, and emotions. If needed, it provides a discussion guide to talking with a medical professional based on answers to its daily screenings. Included in the app are over 150 psychological exercises and videos to promote and strengthen overall mental health. It is useful in introducing how to discuss mental health with a professional. It is available in the App Store and Google Play free of cost.

MindShift CBT

Designed to assist youth and young adults in coping with anxiety, MindShift constructs an individualized toolbox to help individuals deal with test anxiety, perfectionism, social anxiety, worry, panic, and conflict. The app includes directions on how to construct “belief experiments” to test common beliefs that fuel anxiety, guided relaxation, as well as tools and tips to help set and accomplish goals. It is useful in helping teens and young adults learn about helpful and unhelpful anxiety, as well as to overcome fears by gradually facing them in manageable steps. It is available in the App Store and Google Play for free.

CBT-i Coach

CBT-i Coach, based on principles of cognitive behavioral therapy for insomnia (CBT-i), is a structured program to learn about sleep, develop positive sleep routines, and improve sleep environment. The CBT methods used attempt to change behaviors, which in turn provides confidence that patients will sleep better on a regular basis. It useful as a first-line intervention in treating symptoms of insomnia. It is available in the App Store and Google Play for no cost.

Getselfhelp.co.uk

This website provides free self-help and therapy resources grounded in methods that teach the change agents in CBT that can influence negative and destructive thought patterns. Negative thought patterns include thinking in terms of all or nothing: “Nothing ever works out for me,” fortune telling: “I shouldn’t even try,” and overgeneralization: “This didn’t work so this will not either.” Getselfhelp.co.uk provides handouts on a wide array of symptoms related to anxiety, depression, low self-esteem, panic attacks, social disorder, and more. The solution section of the website supplies interventions that can be printed and saved for future use. It is helpful for clinicians and patients in identifying an area of need and creating an action plan. It is also useful for clinicians to have as an augmented supplement for counseling and is free of cost.

The bottom line

When used correctly the resources that we have reviewed can essentially be deployed in a manner similar to how we use finger-stick blood sugar monitoring in the treatment of diabetes. Each of these technologies works best when combined with clinician input and periodic review. When used to supplement clinician counseling, the apps may help sustain motivation and provide insights and exercises that improve patient engagement and supplement the effect of counseling and/or medications that are prescribed in the office.

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.

There is probably no area where human contact is more important than in the area of counseling and psychotherapy. Or so most of us have thought. It turns out that, even in behavioral medicine, technology has made fantastic inroads in helping patients achieve real improvement in troublesome behavioral symptoms. There is good evidence that digital interfaces for cognitive behavioral therapy (CBT) can help in the treatment of anxiety and depression. We will not go over that evidence in this column, other than to say that the evidence is there, but rather we will review some of the best apps that those of us in primary care can utilize in the care of our patients. It is our opinion that these apps are best used in conjunction with our care to supplement the counseling we are giving our patients in the office. Many of the apps listed may be used for both anxiety and depression, as well as in areas related to problem solving, self-esteem, anger management, creating lifestyle changes, and coping with uncertainty.

MoodKit

MoodKit is a CBT app with four main tools: a collection of activities focused on coping self-efficacy (a person’s belief in success in specific situations) that includes individual productivity, social relationships, physical activity, and healthy habits; a thought checker; mood tracker; and journal. MoodKit is accessed in an unstructured way and can be used as an unguided self-help app. It is useful in patient interactions to access interventions in areas such as social engagement and options for choosing a healthy lifestyle. It is available in Apple’s App Store, and it costs $4.99.

Moodnotes

Based on CBT and positive psychology, Moodnotes assists in recognizing and learning about “traps” in thinking, as well as emphasizing healthier thinking habits. Traps in thinking include “catastrophic thinking” where patients with depression may think that a small error or behavioral indiscretion may lead to a consequence that far exceeds what is likely, or “mind-reading” where a person assumes that others are critical of them without actually having evidence that this is the case. Moodnotes tracks mood over a period of time while identifying factors that influence it. It is helpful in between visits to aid clinicians in gaining perspective on mood patterns. It is available in the App Store; it costs $4.99.

MoodMission

This app recommends strategies based in CBT after input of low moods or feelings of anxiety. MoodMission provides five “missions” to engage in that promote confidence in handling stressors and promotes coping self-efficacy. The app learns what style works best and tailors techniques according to when a patient uses it most frequently. Rewards in the app are used to promote motivation and to increase pleasure and self-confidence. It is useful for patients who could use a lift in mood or decrease in symptoms of anxiety and depression. It available in the App Store and Google Play, and it’s free.

 

What’s Up

In line with its development based on principles from CBT and Acceptance and Commitment Therapy (ACT), What’s Up identifies common negative thinking patterns and methods to overcome them with useful metaphors, a catastrophe scale, grounding techniques, and breathing exercises. What’s Up syncs data across multiple devices and uses a unique passcode to protect this information. One of the abilities that separates it from other apps is that it can become active in forums where people discuss similar feelings and strategies that have been useful for them. It is available in the App Store and Google Play, and it’s free.

Moodpath

Moodpath uses daily screenings to create better understanding of thoughts, feelings, and emotions. If needed, it provides a discussion guide to talking with a medical professional based on answers to its daily screenings. Included in the app are over 150 psychological exercises and videos to promote and strengthen overall mental health. It is useful in introducing how to discuss mental health with a professional. It is available in the App Store and Google Play free of cost.

MindShift CBT

Designed to assist youth and young adults in coping with anxiety, MindShift constructs an individualized toolbox to help individuals deal with test anxiety, perfectionism, social anxiety, worry, panic, and conflict. The app includes directions on how to construct “belief experiments” to test common beliefs that fuel anxiety, guided relaxation, as well as tools and tips to help set and accomplish goals. It is useful in helping teens and young adults learn about helpful and unhelpful anxiety, as well as to overcome fears by gradually facing them in manageable steps. It is available in the App Store and Google Play for free.

CBT-i Coach

CBT-i Coach, based on principles of cognitive behavioral therapy for insomnia (CBT-i), is a structured program to learn about sleep, develop positive sleep routines, and improve sleep environment. The CBT methods used attempt to change behaviors, which in turn provides confidence that patients will sleep better on a regular basis. It useful as a first-line intervention in treating symptoms of insomnia. It is available in the App Store and Google Play for no cost.

Getselfhelp.co.uk

This website provides free self-help and therapy resources grounded in methods that teach the change agents in CBT that can influence negative and destructive thought patterns. Negative thought patterns include thinking in terms of all or nothing: “Nothing ever works out for me,” fortune telling: “I shouldn’t even try,” and overgeneralization: “This didn’t work so this will not either.” Getselfhelp.co.uk provides handouts on a wide array of symptoms related to anxiety, depression, low self-esteem, panic attacks, social disorder, and more. The solution section of the website supplies interventions that can be printed and saved for future use. It is helpful for clinicians and patients in identifying an area of need and creating an action plan. It is also useful for clinicians to have as an augmented supplement for counseling and is free of cost.

The bottom line

When used correctly the resources that we have reviewed can essentially be deployed in a manner similar to how we use finger-stick blood sugar monitoring in the treatment of diabetes. Each of these technologies works best when combined with clinician input and periodic review. When used to supplement clinician counseling, the apps may help sustain motivation and provide insights and exercises that improve patient engagement and supplement the effect of counseling and/or medications that are prescribed in the office.

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.

There is probably no area where human contact is more important than in the area of counseling and psychotherapy. Or so most of us have thought. It turns out that, even in behavioral medicine, technology has made fantastic inroads in helping patients achieve real improvement in troublesome behavioral symptoms. There is good evidence that digital interfaces for cognitive behavioral therapy (CBT) can help in the treatment of anxiety and depression. We will not go over that evidence in this column, other than to say that the evidence is there, but rather we will review some of the best apps that those of us in primary care can utilize in the care of our patients. It is our opinion that these apps are best used in conjunction with our care to supplement the counseling we are giving our patients in the office. Many of the apps listed may be used for both anxiety and depression, as well as in areas related to problem solving, self-esteem, anger management, creating lifestyle changes, and coping with uncertainty.

MoodKit

MoodKit is a CBT app with four main tools: a collection of activities focused on coping self-efficacy (a person’s belief in success in specific situations) that includes individual productivity, social relationships, physical activity, and healthy habits; a thought checker; mood tracker; and journal. MoodKit is accessed in an unstructured way and can be used as an unguided self-help app. It is useful in patient interactions to access interventions in areas such as social engagement and options for choosing a healthy lifestyle. It is available in Apple’s App Store, and it costs $4.99.

Moodnotes

Based on CBT and positive psychology, Moodnotes assists in recognizing and learning about “traps” in thinking, as well as emphasizing healthier thinking habits. Traps in thinking include “catastrophic thinking” where patients with depression may think that a small error or behavioral indiscretion may lead to a consequence that far exceeds what is likely, or “mind-reading” where a person assumes that others are critical of them without actually having evidence that this is the case. Moodnotes tracks mood over a period of time while identifying factors that influence it. It is helpful in between visits to aid clinicians in gaining perspective on mood patterns. It is available in the App Store; it costs $4.99.

MoodMission

This app recommends strategies based in CBT after input of low moods or feelings of anxiety. MoodMission provides five “missions” to engage in that promote confidence in handling stressors and promotes coping self-efficacy. The app learns what style works best and tailors techniques according to when a patient uses it most frequently. Rewards in the app are used to promote motivation and to increase pleasure and self-confidence. It is useful for patients who could use a lift in mood or decrease in symptoms of anxiety and depression. It available in the App Store and Google Play, and it’s free.

 

What’s Up

In line with its development based on principles from CBT and Acceptance and Commitment Therapy (ACT), What’s Up identifies common negative thinking patterns and methods to overcome them with useful metaphors, a catastrophe scale, grounding techniques, and breathing exercises. What’s Up syncs data across multiple devices and uses a unique passcode to protect this information. One of the abilities that separates it from other apps is that it can become active in forums where people discuss similar feelings and strategies that have been useful for them. It is available in the App Store and Google Play, and it’s free.

Moodpath

Moodpath uses daily screenings to create better understanding of thoughts, feelings, and emotions. If needed, it provides a discussion guide to talking with a medical professional based on answers to its daily screenings. Included in the app are over 150 psychological exercises and videos to promote and strengthen overall mental health. It is useful in introducing how to discuss mental health with a professional. It is available in the App Store and Google Play free of cost.

MindShift CBT

Designed to assist youth and young adults in coping with anxiety, MindShift constructs an individualized toolbox to help individuals deal with test anxiety, perfectionism, social anxiety, worry, panic, and conflict. The app includes directions on how to construct “belief experiments” to test common beliefs that fuel anxiety, guided relaxation, as well as tools and tips to help set and accomplish goals. It is useful in helping teens and young adults learn about helpful and unhelpful anxiety, as well as to overcome fears by gradually facing them in manageable steps. It is available in the App Store and Google Play for free.

CBT-i Coach

CBT-i Coach, based on principles of cognitive behavioral therapy for insomnia (CBT-i), is a structured program to learn about sleep, develop positive sleep routines, and improve sleep environment. The CBT methods used attempt to change behaviors, which in turn provides confidence that patients will sleep better on a regular basis. It useful as a first-line intervention in treating symptoms of insomnia. It is available in the App Store and Google Play for no cost.

Getselfhelp.co.uk

This website provides free self-help and therapy resources grounded in methods that teach the change agents in CBT that can influence negative and destructive thought patterns. Negative thought patterns include thinking in terms of all or nothing: “Nothing ever works out for me,” fortune telling: “I shouldn’t even try,” and overgeneralization: “This didn’t work so this will not either.” Getselfhelp.co.uk provides handouts on a wide array of symptoms related to anxiety, depression, low self-esteem, panic attacks, social disorder, and more. The solution section of the website supplies interventions that can be printed and saved for future use. It is helpful for clinicians and patients in identifying an area of need and creating an action plan. It is also useful for clinicians to have as an augmented supplement for counseling and is free of cost.

The bottom line

When used correctly the resources that we have reviewed can essentially be deployed in a manner similar to how we use finger-stick blood sugar monitoring in the treatment of diabetes. Each of these technologies works best when combined with clinician input and periodic review. When used to supplement clinician counseling, the apps may help sustain motivation and provide insights and exercises that improve patient engagement and supplement the effect of counseling and/or medications that are prescribed in the office.

Dr. Skolnik is professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Aaron Sutton is a behavioral health consultant and faculty member in the family medicine residency program at Abington Jefferson Health.