Thomas R. Collins

As hospitalists and other physicians at the University of Texas at Austin considered how to treat COVID-19 patients in the early weeks of the pandemic, one question they had to consider was: What about convalescent plasma?

All they had to go on were small case series in Ebola, SARS, and MERS and a few small, nonrandomized COVID-19 studies showing a possible benefit and minimal risk, but the evidence was only “toward the middle or bottom” of the evidence pyramid, said Johanna Busch, MD, of the department of internal medicine at Dell Medical Center at the university.

The center’s COVID-19 committee asked a few of its members – infectious disease and internal medicine physicians – to analyze the literature and other factors. In the end, the committee – which meets regularly and also includes pulmonology–critical care experts, nursing experts, and others – recommended using convalescent plasma because of the evidence and the available supply. But in subsequent meetings, as the pandemic surged in the South and the supply dwindled, the committee changed its recommendation for convalescent plasma to more limited use, she said during the virtual annual meeting of the Society of Hospital Medicine.

Dell’s experience with the therapy is one example of how the center had to quickly develop protocols for managing a pandemic with essentially no solid evidence for treatment and a system that had never been challenged before to the same degree.

“It’s all about teamwork,” said W. Michael Brode, MD, of the department of internal medicine at Dell. “The interprofessional team members know their roles and have shared expectations because they have a common understanding of the protocol.” It’s okay to deviate from the protocol, he said, as long as the language exists to communicate these deviations.

“Maybe the approach is more important than the actual content,” he said.

What Dr. Brode and Dr. Busch described was in large part a fine-tuning of communication – being available to communicate in real time and being aware of when certain specialists should be contacted – for instance, to determine at what oxygenation level internal medicine staff should get in touch with the pulmonary–critical care team.

Dr. Brode said that the groundwork is laid for productive meetings, with agendas announced ahead of time and readings assigned and presenters ready with near-finished products at meeting time, “with a clear path for operationalizing it.”

“We don’t want people kind of riffing off the top of their heads,” he said.

Committee members are encouraged to be as specific as possible when giving input into COVID-19 care decisions, he said.

“We’re so used to dealing with uncertainty, but that doesn’t really help when we’re trying to make tough decisions,” Dr. Brode said. They might be asked, “What are you going to write in your consult note template?” or “It’s 1:00 a.m. and your intern’s panicked and calling you – what are you going to tell them to do over the phone?”

The recommendations have to go into writing and are incorporated into the electronic medical record, a process that required some workarounds, he said. He also noted that the committee learned early on that they should assume that no one reads the e-mails – especially after being off for a period of time – so they likely won’t digest updates on an email-by-email basis.

“We quickly learned,” Dr. Brode said, “that this information needs to live on a Web site or [be] linked to the most up-to-date version in a cloud-sharing platform.”

In a question-and-answer discussion, session viewers expressed enthusiasm for the presenters’ one-page summary of protocols – much more, they said, and it could feel overwhelming.

Dr. Busch and Dr. Brode were asked how standardized order sets for COVID patients could be justified without comparison to a control group that didn’t use the standard order set.

Dr. Busch responded that, while there was no controlled trial, the order sets they use have evolved based on experience.

“At the beginning, we were following every inflammatory marker known to mankind, and then we realized as we gained more experience with COVID and COVID patients that some of those markers were not really informing any of our clinical decisions,” she said. “Obviously, as literature comes out we may reevaluate what goes into that standard order set and how frequently we follow labs.”

Dr. Brode said the context – a pandemic – has to be considered.

“In an ideal world, we could show that the intervention is superior through a randomized fashion with a control group, but really our thought process behind it is just, what is the default?” he said. “I looked at the order sets [as] not that they’re going to be dictating care, but it’s really like the guardrails of what’s reasonable. And when you’re in the middle of a surge, what is usually reasonable and easiest is what is going to be done.”

Dr. Busch and Dr. Brode reported no relevant financial relationships.

As hospitalists and other physicians at the University of Texas at Austin considered how to treat COVID-19 patients in the early weeks of the pandemic, one question they had to consider was: What about convalescent plasma?

All they had to go on were small case series in Ebola, SARS, and MERS and a few small, nonrandomized COVID-19 studies showing a possible benefit and minimal risk, but the evidence was only “toward the middle or bottom” of the evidence pyramid, said Johanna Busch, MD, of the department of internal medicine at Dell Medical Center at the university.

The center’s COVID-19 committee asked a few of its members – infectious disease and internal medicine physicians – to analyze the literature and other factors. In the end, the committee – which meets regularly and also includes pulmonology–critical care experts, nursing experts, and others – recommended using convalescent plasma because of the evidence and the available supply. But in subsequent meetings, as the pandemic surged in the South and the supply dwindled, the committee changed its recommendation for convalescent plasma to more limited use, she said during the virtual annual meeting of the Society of Hospital Medicine.

Dell’s experience with the therapy is one example of how the center had to quickly develop protocols for managing a pandemic with essentially no solid evidence for treatment and a system that had never been challenged before to the same degree.

“It’s all about teamwork,” said W. Michael Brode, MD, of the department of internal medicine at Dell. “The interprofessional team members know their roles and have shared expectations because they have a common understanding of the protocol.” It’s okay to deviate from the protocol, he said, as long as the language exists to communicate these deviations.

“Maybe the approach is more important than the actual content,” he said.

What Dr. Brode and Dr. Busch described was in large part a fine-tuning of communication – being available to communicate in real time and being aware of when certain specialists should be contacted – for instance, to determine at what oxygenation level internal medicine staff should get in touch with the pulmonary–critical care team.

Dr. Brode said that the groundwork is laid for productive meetings, with agendas announced ahead of time and readings assigned and presenters ready with near-finished products at meeting time, “with a clear path for operationalizing it.”

“We don’t want people kind of riffing off the top of their heads,” he said.

Committee members are encouraged to be as specific as possible when giving input into COVID-19 care decisions, he said.

“We’re so used to dealing with uncertainty, but that doesn’t really help when we’re trying to make tough decisions,” Dr. Brode said. They might be asked, “What are you going to write in your consult note template?” or “It’s 1:00 a.m. and your intern’s panicked and calling you – what are you going to tell them to do over the phone?”

The recommendations have to go into writing and are incorporated into the electronic medical record, a process that required some workarounds, he said. He also noted that the committee learned early on that they should assume that no one reads the e-mails – especially after being off for a period of time – so they likely won’t digest updates on an email-by-email basis.

“We quickly learned,” Dr. Brode said, “that this information needs to live on a Web site or [be] linked to the most up-to-date version in a cloud-sharing platform.”

In a question-and-answer discussion, session viewers expressed enthusiasm for the presenters’ one-page summary of protocols – much more, they said, and it could feel overwhelming.

Dr. Busch and Dr. Brode were asked how standardized order sets for COVID patients could be justified without comparison to a control group that didn’t use the standard order set.

Dr. Busch responded that, while there was no controlled trial, the order sets they use have evolved based on experience.

“At the beginning, we were following every inflammatory marker known to mankind, and then we realized as we gained more experience with COVID and COVID patients that some of those markers were not really informing any of our clinical decisions,” she said. “Obviously, as literature comes out we may reevaluate what goes into that standard order set and how frequently we follow labs.”

Dr. Brode said the context – a pandemic – has to be considered.

“In an ideal world, we could show that the intervention is superior through a randomized fashion with a control group, but really our thought process behind it is just, what is the default?” he said. “I looked at the order sets [as] not that they’re going to be dictating care, but it’s really like the guardrails of what’s reasonable. And when you’re in the middle of a surge, what is usually reasonable and easiest is what is going to be done.”

Dr. Busch and Dr. Brode reported no relevant financial relationships.

As hospitalists and other physicians at the University of Texas at Austin considered how to treat COVID-19 patients in the early weeks of the pandemic, one question they had to consider was: What about convalescent plasma?

All they had to go on were small case series in Ebola, SARS, and MERS and a few small, nonrandomized COVID-19 studies showing a possible benefit and minimal risk, but the evidence was only “toward the middle or bottom” of the evidence pyramid, said Johanna Busch, MD, of the department of internal medicine at Dell Medical Center at the university.

The center’s COVID-19 committee asked a few of its members – infectious disease and internal medicine physicians – to analyze the literature and other factors. In the end, the committee – which meets regularly and also includes pulmonology–critical care experts, nursing experts, and others – recommended using convalescent plasma because of the evidence and the available supply. But in subsequent meetings, as the pandemic surged in the South and the supply dwindled, the committee changed its recommendation for convalescent plasma to more limited use, she said during the virtual annual meeting of the Society of Hospital Medicine.

Dell’s experience with the therapy is one example of how the center had to quickly develop protocols for managing a pandemic with essentially no solid evidence for treatment and a system that had never been challenged before to the same degree.

“It’s all about teamwork,” said W. Michael Brode, MD, of the department of internal medicine at Dell. “The interprofessional team members know their roles and have shared expectations because they have a common understanding of the protocol.” It’s okay to deviate from the protocol, he said, as long as the language exists to communicate these deviations.

“Maybe the approach is more important than the actual content,” he said.

What Dr. Brode and Dr. Busch described was in large part a fine-tuning of communication – being available to communicate in real time and being aware of when certain specialists should be contacted – for instance, to determine at what oxygenation level internal medicine staff should get in touch with the pulmonary–critical care team.

Dr. Brode said that the groundwork is laid for productive meetings, with agendas announced ahead of time and readings assigned and presenters ready with near-finished products at meeting time, “with a clear path for operationalizing it.”

“We don’t want people kind of riffing off the top of their heads,” he said.

Committee members are encouraged to be as specific as possible when giving input into COVID-19 care decisions, he said.

“We’re so used to dealing with uncertainty, but that doesn’t really help when we’re trying to make tough decisions,” Dr. Brode said. They might be asked, “What are you going to write in your consult note template?” or “It’s 1:00 a.m. and your intern’s panicked and calling you – what are you going to tell them to do over the phone?”

The recommendations have to go into writing and are incorporated into the electronic medical record, a process that required some workarounds, he said. He also noted that the committee learned early on that they should assume that no one reads the e-mails – especially after being off for a period of time – so they likely won’t digest updates on an email-by-email basis.

“We quickly learned,” Dr. Brode said, “that this information needs to live on a Web site or [be] linked to the most up-to-date version in a cloud-sharing platform.”

In a question-and-answer discussion, session viewers expressed enthusiasm for the presenters’ one-page summary of protocols – much more, they said, and it could feel overwhelming.

Dr. Busch and Dr. Brode were asked how standardized order sets for COVID patients could be justified without comparison to a control group that didn’t use the standard order set.

Dr. Busch responded that, while there was no controlled trial, the order sets they use have evolved based on experience.

“At the beginning, we were following every inflammatory marker known to mankind, and then we realized as we gained more experience with COVID and COVID patients that some of those markers were not really informing any of our clinical decisions,” she said. “Obviously, as literature comes out we may reevaluate what goes into that standard order set and how frequently we follow labs.”

Dr. Brode said the context – a pandemic – has to be considered.

“In an ideal world, we could show that the intervention is superior through a randomized fashion with a control group, but really our thought process behind it is just, what is the default?” he said. “I looked at the order sets [as] not that they’re going to be dictating care, but it’s really like the guardrails of what’s reasonable. And when you’re in the middle of a surge, what is usually reasonable and easiest is what is going to be done.”

Dr. Busch and Dr. Brode reported no relevant financial relationships.

Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.

Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.

“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.

In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.

The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.

“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.

Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.

“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.

Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)

Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.

“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.

“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
 

SHM advocacy on immigration issues

SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.

The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:

The Fairness for High Skilled Immigrants Act

• This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
• This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.

The Conrad State 30 Physician Reauthorization Act

• This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
•  

The Healthcare Workforce Resilience Act

• This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
• This legislation will only be in effect for the duration of the COVID-19 public health emergency.

To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
 

Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.

Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.

“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.

In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.

The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.

“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.

Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.

“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.

Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)

Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.

“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.

“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
 

SHM advocacy on immigration issues

SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.

The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:

The Fairness for High Skilled Immigrants Act

• This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
• This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.

The Conrad State 30 Physician Reauthorization Act

• This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
•  

The Healthcare Workforce Resilience Act

• This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
• This legislation will only be in effect for the duration of the COVID-19 public health emergency.

To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
 

Manpreet Malik, MD, a hospitalist at Emory University, takes care of patients with COVID-19 at Grady Memorial Hospital in downtown Atlanta. Born in India but living in the United States for more than 10 years, he is awaiting permanent resident status. At the current pace of U.S. Citizenship and Immigration Services, that may be decades away.

Dr. Malik lives and works in the United States on an H-1B visa, which is based on employment in a specialty occupation. Although he has a job that he loves, his immigrant status, social life, and geographic location in the United States is, technically, entirely dependent on doing that job.

“For single-income families with doctors on visas, the pandemic brings anxiety and uncertainty about legal status in the U.S. in case the breadwinner gets sick, disabled or unemployed,” he said.

In a presentation to be given at the HM20 Virtual, hosted by the Society of Hospital Medicine, Dr. Malik will offer perspective on the current challenges facing immigrant hospitalists and health care workers, especially in a U.S. health care system stretched thin and one in which many health professionals born outside the United States are working on the front lines. These challenges should be motivation to make legislative changes to give these health care workers more stability, flexibility, and peace of mind, he said.

The talk – to be given along with HM20 course director Benji Mathews, MD, SFHM, and called “The Immigrant Hospitalist: Navigating the Uncertain Terrain During COVID-19” – will describe a long-standing issue and outline a path forward, the two physicians said.

“The objective of this talk is to really highlight the contributions of these physicians and health care workers and also to provide a call for action for our hospitalist colleagues. This talk paints a picture of what my family and thousands of the other immigrant health care worker families are going through,” Dr. Malik said.

Dr. Mathews said that many physicians do not have benefits they can fall back on should they fall ill. And without the jobs their visas are based on, they could face deportation.

“That’s extreme – but the pathway towards that is very much there,” said Dr. Mathews, who was born in the Middle East and immigrated to the United States, received a green card, and later his citizenship. He now advocates for immigrant health and immigrant health care workers.

Dr. Malik and Dr. Mathews recently published a perspective piece in the Journal of Hospital Medicine. In it, they pointed out that 16.4% of health care workers are immigrants, and 29% of physicians are immigrants. Among practicing hospitalists, 32% are international medical graduates. They called for reform to visa regulations to allow physicians who are immigrants to travel to areas where they are most needed during the pandemic, for extensions of visa deadlines, and exemption from future immigration bans or limitations. These measures would only bolster the health care workforce that is under such strain during the pandemic, they write. (J Hosp Med. 2020 Aug;15[8]:505-506)

Dr. Malik said that, even while under added personal strain caused by the uncertainty of the past several months, he has never questioned his decision to be a physician in the United States.

“Now, more than ever, there is a sense of purpose and a passion to make a difference for our patients,” he said.

“I think most of us get into medicine and become hospitalists because we want to care for people, because we want to serve, because we want to be able to take care of sick, hospitalized patients, and that can be anywhere in the world, whether you’re in India serving a population that you grew up with or whether you’re in the U.S. serving the population that are your neighbors, your friends, your community, or people that are vulnerable. You’re serving humanity, and that is the ultimate goal.”
 

SHM advocacy on immigration issues

SHM has been advocating for more equitable skilled-immigration system, recognizing that from visa-backlogs to per-country caps, unfair visa restrictions have limited the United States’ ability to adequately expand its health care workforce.

The Society has consistently advocated on Capitol Hill for visa and skilled-immigration reform and has championed several significant immigration bills, including the following:

The Fairness for High Skilled Immigrants Act

• This legislation will eliminate per-country caps on green cards and convert the system into a “first-come, first-serve” system. This will help ensure certain nationalize are not disproportionally impacted by excessive green card backlogs.
• This legislation has passed the House of Representatives. Send a message to your Senator asking them to cosponsor this legislation.

The Conrad State 30 Physician Reauthorization Act

• This legislation will renew the Conrad State 30 program, which allows physicians on a J-1 visa to remain in the United States if they work in an underserved region for a minimum of three years. This legislation also included additional employment protection claims.
•  

The Healthcare Workforce Resilience Act

• This legislation will recapture 40,000 unused immigrant visas for foreign doctors (15,000) and nurses (25,000), as well as provide visas for their spouse and children.
• This legislation will only be in effect for the duration of the COVID-19 public health emergency.

To join SHM in supporting our immigrant clinicians, you can send a message to your representatives in support of these bills by visiting hospitalmedicine.org/takeaction.
 

Nathan Chomilo, MD, the Medicaid medical director for the state of Minnesota and assistant adjunct professor of pediatrics at the University of Minnesota, Minneapolis, was prepared to deliver a talk on structural racism in the U.S. health care system at Hospital Medicine 2020 meeting (HM20) in April 2020. But that changed in the COVID-19 era.

When the pandemic hit, the problems Dr. Chomilo was going to point out began to play out dramatically around the country: Black, Indigenous, and Latinx people – many of them under-insured; in high-exposure, frontline jobs; and already burdened with health comorbidities – are at a higher risk of contracting COVID-19 and dying from it.

He will now be giving his talk at HM20 Virtual in a session called “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” with the powerful narrative of COVID-19 to get his message to sink in: For centuries, the medical field and the health care system more broadly have enabled racism to play out in a structural way, and this is leading to sickness and death.

“It’s something that’s been going on since the start of our country,” said Dr. Chomilo, who is also a founding member of Minnesota Doctors for Health Equity. Physicians, he said, participated in upholding the institution of slavery by trying to describe the physical discrepancies between White people and non-White people.

Now, the way health care is provided in the United States fundamentally favors Whites over Black, Indigenous, and Latinx patients.

“We have a health care system here in the United States that is based on employer-sponsored insurance,” he said. “And who has had access to those jobs over the course of our country’s history has been mostly White people.” That impacts who is more at risk of contracting the virus, who is able to shelter in place, and who has the financial reserves to withstand furloughs and unemployment.

In a recent blog post in Health Affairs, Dr. Chomilo and his coauthors discussed articles from the New England Journal of Medicine and the Journal of the American Medical Association that try to offer an ethical framework for allocating scarce medical resources – such as intensive-care beds and ventilators – during the pandemic.

“Unfortunately, neither article acknowledged the structural racial inequities that inherently bias its proposals, nor did either piece adequately acknowledge how its care rationing plan might worsen already racially disparate health outcomes,” Dr. Chomilo and his coauthors wrote. For instance, the life expectancy of a White female in the United States is 81 years, compared with 72 years for Black males, and any allocation plan that prioritizes preserving years of life would automatically be tilted against black patients.

In his talk, Dr. Chomilo will also discuss how physicians can make a difference by looking at their own perceptions and habits and then start helping others and the systems in which they work.

“The first thing is, we have to look at ourselves,” he said.

In the same session, Benji Mathews, MD, SFHM – chief of hospital medicine at Regions Hospital in St. Paul, Minn., which is part of HealthPartners; associate professor of medicine at the University of Minnesota, Minneapolis; and the Annual Conference’s course director – said he will be discussing the way social inequities are “patterned by place” and how resources for staying healthy vary neighborhood to neighborhood. He will point to dense housing and multigenerational households as a chief driver of COVID-19 infection risk. People of color are often “first fired, last hired, and in the front lines of fire,” he said, and they are experiencing a more severe impact from the pandemic.

And he will get deeper into the other disparities that track along racial lines, such as insurance disparities. For instance, the percentage of African Americans on Medicaid is three times as high as the percentage of White, non-Hispanic patients, he said.

Dr. Mathews will also discuss race’s role in the biases that everyone has and how health care professionals might, with deliberate reflection, be able to reshape or mitigate their own biases and deliver care more equitably.

“The associations we have, and our biases, are not necessarily declared beliefs or even reflect our stances that we explicitly endorse – sometimes it comes through in our default stance, and generally favor our in-group,” he said. “These implicit biases are malleable, so that allows us some hope. There are some ways they can be unlearned or progressively acted upon with some coaching – some active, intentional development.”
 

Structural Racism and Bias in Hospital Medicine During Two Pandemics

Nathan Chomilo, MD, the Medicaid medical director for the state of Minnesota and assistant adjunct professor of pediatrics at the University of Minnesota, Minneapolis, was prepared to deliver a talk on structural racism in the U.S. health care system at Hospital Medicine 2020 meeting (HM20) in April 2020. But that changed in the COVID-19 era.

When the pandemic hit, the problems Dr. Chomilo was going to point out began to play out dramatically around the country: Black, Indigenous, and Latinx people – many of them under-insured; in high-exposure, frontline jobs; and already burdened with health comorbidities – are at a higher risk of contracting COVID-19 and dying from it.

He will now be giving his talk at HM20 Virtual in a session called “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” with the powerful narrative of COVID-19 to get his message to sink in: For centuries, the medical field and the health care system more broadly have enabled racism to play out in a structural way, and this is leading to sickness and death.

“It’s something that’s been going on since the start of our country,” said Dr. Chomilo, who is also a founding member of Minnesota Doctors for Health Equity. Physicians, he said, participated in upholding the institution of slavery by trying to describe the physical discrepancies between White people and non-White people.

Now, the way health care is provided in the United States fundamentally favors Whites over Black, Indigenous, and Latinx patients.

“We have a health care system here in the United States that is based on employer-sponsored insurance,” he said. “And who has had access to those jobs over the course of our country’s history has been mostly White people.” That impacts who is more at risk of contracting the virus, who is able to shelter in place, and who has the financial reserves to withstand furloughs and unemployment.

In a recent blog post in Health Affairs, Dr. Chomilo and his coauthors discussed articles from the New England Journal of Medicine and the Journal of the American Medical Association that try to offer an ethical framework for allocating scarce medical resources – such as intensive-care beds and ventilators – during the pandemic.

“Unfortunately, neither article acknowledged the structural racial inequities that inherently bias its proposals, nor did either piece adequately acknowledge how its care rationing plan might worsen already racially disparate health outcomes,” Dr. Chomilo and his coauthors wrote. For instance, the life expectancy of a White female in the United States is 81 years, compared with 72 years for Black males, and any allocation plan that prioritizes preserving years of life would automatically be tilted against black patients.

In his talk, Dr. Chomilo will also discuss how physicians can make a difference by looking at their own perceptions and habits and then start helping others and the systems in which they work.

“The first thing is, we have to look at ourselves,” he said.

In the same session, Benji Mathews, MD, SFHM – chief of hospital medicine at Regions Hospital in St. Paul, Minn., which is part of HealthPartners; associate professor of medicine at the University of Minnesota, Minneapolis; and the Annual Conference’s course director – said he will be discussing the way social inequities are “patterned by place” and how resources for staying healthy vary neighborhood to neighborhood. He will point to dense housing and multigenerational households as a chief driver of COVID-19 infection risk. People of color are often “first fired, last hired, and in the front lines of fire,” he said, and they are experiencing a more severe impact from the pandemic.

And he will get deeper into the other disparities that track along racial lines, such as insurance disparities. For instance, the percentage of African Americans on Medicaid is three times as high as the percentage of White, non-Hispanic patients, he said.

Dr. Mathews will also discuss race’s role in the biases that everyone has and how health care professionals might, with deliberate reflection, be able to reshape or mitigate their own biases and deliver care more equitably.

“The associations we have, and our biases, are not necessarily declared beliefs or even reflect our stances that we explicitly endorse – sometimes it comes through in our default stance, and generally favor our in-group,” he said. “These implicit biases are malleable, so that allows us some hope. There are some ways they can be unlearned or progressively acted upon with some coaching – some active, intentional development.”
 

Structural Racism and Bias in Hospital Medicine During Two Pandemics

Nathan Chomilo, MD, the Medicaid medical director for the state of Minnesota and assistant adjunct professor of pediatrics at the University of Minnesota, Minneapolis, was prepared to deliver a talk on structural racism in the U.S. health care system at Hospital Medicine 2020 meeting (HM20) in April 2020. But that changed in the COVID-19 era.

When the pandemic hit, the problems Dr. Chomilo was going to point out began to play out dramatically around the country: Black, Indigenous, and Latinx people – many of them under-insured; in high-exposure, frontline jobs; and already burdened with health comorbidities – are at a higher risk of contracting COVID-19 and dying from it.

He will now be giving his talk at HM20 Virtual in a session called “Structural Racism and Bias in Hospital Medicine During Two Pandemics,” with the powerful narrative of COVID-19 to get his message to sink in: For centuries, the medical field and the health care system more broadly have enabled racism to play out in a structural way, and this is leading to sickness and death.

“It’s something that’s been going on since the start of our country,” said Dr. Chomilo, who is also a founding member of Minnesota Doctors for Health Equity. Physicians, he said, participated in upholding the institution of slavery by trying to describe the physical discrepancies between White people and non-White people.

Now, the way health care is provided in the United States fundamentally favors Whites over Black, Indigenous, and Latinx patients.

“We have a health care system here in the United States that is based on employer-sponsored insurance,” he said. “And who has had access to those jobs over the course of our country’s history has been mostly White people.” That impacts who is more at risk of contracting the virus, who is able to shelter in place, and who has the financial reserves to withstand furloughs and unemployment.

In a recent blog post in Health Affairs, Dr. Chomilo and his coauthors discussed articles from the New England Journal of Medicine and the Journal of the American Medical Association that try to offer an ethical framework for allocating scarce medical resources – such as intensive-care beds and ventilators – during the pandemic.

“Unfortunately, neither article acknowledged the structural racial inequities that inherently bias its proposals, nor did either piece adequately acknowledge how its care rationing plan might worsen already racially disparate health outcomes,” Dr. Chomilo and his coauthors wrote. For instance, the life expectancy of a White female in the United States is 81 years, compared with 72 years for Black males, and any allocation plan that prioritizes preserving years of life would automatically be tilted against black patients.

In his talk, Dr. Chomilo will also discuss how physicians can make a difference by looking at their own perceptions and habits and then start helping others and the systems in which they work.

“The first thing is, we have to look at ourselves,” he said.

In the same session, Benji Mathews, MD, SFHM – chief of hospital medicine at Regions Hospital in St. Paul, Minn., which is part of HealthPartners; associate professor of medicine at the University of Minnesota, Minneapolis; and the Annual Conference’s course director – said he will be discussing the way social inequities are “patterned by place” and how resources for staying healthy vary neighborhood to neighborhood. He will point to dense housing and multigenerational households as a chief driver of COVID-19 infection risk. People of color are often “first fired, last hired, and in the front lines of fire,” he said, and they are experiencing a more severe impact from the pandemic.

And he will get deeper into the other disparities that track along racial lines, such as insurance disparities. For instance, the percentage of African Americans on Medicaid is three times as high as the percentage of White, non-Hispanic patients, he said.

Dr. Mathews will also discuss race’s role in the biases that everyone has and how health care professionals might, with deliberate reflection, be able to reshape or mitigate their own biases and deliver care more equitably.

“The associations we have, and our biases, are not necessarily declared beliefs or even reflect our stances that we explicitly endorse – sometimes it comes through in our default stance, and generally favor our in-group,” he said. “These implicit biases are malleable, so that allows us some hope. There are some ways they can be unlearned or progressively acted upon with some coaching – some active, intentional development.”
 

Structural Racism and Bias in Hospital Medicine During Two Pandemics

Sarah Jones, PA-C, is a physician assistant on the overnight hospitalist team at Indiana University Health Methodist Hospital in Indianapolis, where she has worked for about 8 years. She studied chemistry and biology as an undergraduate at the University of Indianapolis, and then attended PA school at Butler University in Indianapolis. She came out as lesbian/queer just before PA school. She joined the Society of Hospital Medicine in 2020 and serves on SHM’s Diversity and Inclusion Special Interest Group.

How important is it to you to openly identify as a physician assistant who is a member of the LGBTQ community?

I think it’s important to show other people that I am part of the LGBTQ community and that I’ve been able to overcome obstacles and pursue this career and be successful. I can help other people and be in that role [of mentor], and show people that they can do it, too.

What challenges have you faced because of your sexual orientation in the different stages of your career, from training to practicing as a physician assistant?

When my training started, I was much closer to the time when I came out, so my confidence level was a little bit low. I was much more fearful at that point about how people would view me – if I would be thought of as inferior, or not taken as seriously, or that I wasn’t intelligent. I think over the years I’ve grown into this role and it’s helped me become more confident, because I know who I am now. And it’s not something that definitely defines me but I’m confident that I know medicine, and I know how to treat patients and that confidence has gotten much better.

So far at work, everyone’s been great, all my coworkers have been great. I’ve never once felt that my sexuality was holding anyone back from getting to know me better.
 

Have you heard about the experiences of other LGBTQ clinicians who may not have been as fortunate as you, especially transgender people?

There is just a lot of ignorance around LGBTQ persons and especially transgender persons, because people don’t understand it, they don’t get it. So their first inclination is to not approve of it, or be scared of it, or just automatically think that it’s wrong.

If someone’s sexuality comes across much more “obviously” than that of other people, for example, if there’s a gay man who’s a little more flamboyant, [it could be an issue for some patients]. I know there are some gay male nurses who have had patients who don’t want them serving as their nurse, because they’re “obviously” gay. Or a queer woman clinician who has more of an edgier haircut or looks a little bit more masculine; I know that there have been some patients who have said certain things to them that have been discriminating.
 

Have you been especially conscious of how you ‘wear’ your sexual orientation? Have you ever had to change how you’ve presented yourself, lest you have some unpleasant reaction?

I think initially, yes. I would say I’m a little more on the androgynous side with my style. When I was coming out I was trying to figure out where I was and who I was and how I wanted to be, and for the longest time I was dressing more femininely and I wasn’t as comfortable. Since then, I’ve had times where I’ve had short hair or a little bit more of a masculine haircut and wear more masculine clothes and things like that, and I feel much more comfortable doing that.

It’s kind of hard to play the part of a more masculine LGBTQ person at work when you just wear scrubs. I probably don’t portray it as much – I don’t make it as obvious as some other people, but I’ve definitely never shied away from having a conversation with anyone about it.
 

Health care is an intimate profession because of your close interaction with patients and others. Did being a member of the LGBTQ community factor into your decision to enter the health care field, either for or against?

There were times when I didn’t feel well or my mental health was not great because I didn’t know where I was, or hadn’t accepted myself, and I really needed someone who could help me talk through things and try to figure out what my life path was going to be. When I figured those things out with the help of other people, it was life-changing. I respected those people, and that’s what I wanted to do and how I wanted to help. I think that was part of why I got into medicine.

What progress have you seen with regard to LGBTQ health care professionals and patients over the past 5 to 10 years, including subtle changes in culture, attitude, or workplace policies?

Just being interviewed for a profile like this is a step in the right direction. Never once did I think that I would be highlighted for being an LGBTQ person, especially in the workplace.

I think that there are more companies, particularly in health care, and more hospitals that are coming out in support of their LGBTQ employees, especially during Pride month. IU Health walks every year in the Pride parade, which last year was about 3 hours long. Five years previously it was only 30 minutes long. So there are more employers getting involved and recognizing their employees as well. Companies and health care facilities are trying to be more cognizant of their LGBTQ employees and patients and trying to make them more comfortable.
 

What main steps toward more progress would you like to see?

There needs to be greater understanding that people who undergo discrimination actually have more negative health outcomes like heart disease, high blood pressure, and stroke. There needs to be better medical coverage in the LGBTQ community, especially for transgender persons and LGBTQ people who are trying to start families. We need better mental health access, more affordable mental health access, particularly for LGBTQ youth, and we definitely need to continue to raise awareness with hopes that we can eradicate the violence against, and killing of, black transgender persons.

How do you see the Society of Hospital Medicine’s role in this regard?

SHM has a big platform and can certainly reach a lot of people, especially hospitalists who see LGBTQ patients every day. With SHM’s help and the continued training of hospitalists who are members of the society, we can reach out to other clinicians, and to their organizations, and help teach them. SHM really has a good platform to be able to do that, and do it well.

Can you recall a specific interaction with an LGBTQ patient that left you with a potent feeling that “this is what it’s all about”?

I do remember a transgender patient who was homeless. They didn’t have insurance, they couldn’t afford their hormone treatment, and I remember they were struggling with some mental health issues and were “acting out” overnight. Some of the nurses were not using the correct pronouns. I’m more cognizant of their struggles because I’m a member of the LGBTQ community and I was able to recognize this.

I sat down and I talked with the patient for quite a while, we were able to form a bond, and I was able to get a little bit more information from them, and by the end of the night, they felt much better. And just being able to be their voice, when they weren’t able to express exactly how they were feeling, was something that made me thankful that I went into medicine, to help other LGBTQ patients.

I’ve had many LGBTQ patients in the hospital whom I’ve been able to form a bit of a bond with, just knowing that the patient could be me.

Sarah Jones, PA-C, is a physician assistant on the overnight hospitalist team at Indiana University Health Methodist Hospital in Indianapolis, where she has worked for about 8 years. She studied chemistry and biology as an undergraduate at the University of Indianapolis, and then attended PA school at Butler University in Indianapolis. She came out as lesbian/queer just before PA school. She joined the Society of Hospital Medicine in 2020 and serves on SHM’s Diversity and Inclusion Special Interest Group.

How important is it to you to openly identify as a physician assistant who is a member of the LGBTQ community?

I think it’s important to show other people that I am part of the LGBTQ community and that I’ve been able to overcome obstacles and pursue this career and be successful. I can help other people and be in that role [of mentor], and show people that they can do it, too.

What challenges have you faced because of your sexual orientation in the different stages of your career, from training to practicing as a physician assistant?

When my training started, I was much closer to the time when I came out, so my confidence level was a little bit low. I was much more fearful at that point about how people would view me – if I would be thought of as inferior, or not taken as seriously, or that I wasn’t intelligent. I think over the years I’ve grown into this role and it’s helped me become more confident, because I know who I am now. And it’s not something that definitely defines me but I’m confident that I know medicine, and I know how to treat patients and that confidence has gotten much better.

So far at work, everyone’s been great, all my coworkers have been great. I’ve never once felt that my sexuality was holding anyone back from getting to know me better.
 

Have you heard about the experiences of other LGBTQ clinicians who may not have been as fortunate as you, especially transgender people?

There is just a lot of ignorance around LGBTQ persons and especially transgender persons, because people don’t understand it, they don’t get it. So their first inclination is to not approve of it, or be scared of it, or just automatically think that it’s wrong.

If someone’s sexuality comes across much more “obviously” than that of other people, for example, if there’s a gay man who’s a little more flamboyant, [it could be an issue for some patients]. I know there are some gay male nurses who have had patients who don’t want them serving as their nurse, because they’re “obviously” gay. Or a queer woman clinician who has more of an edgier haircut or looks a little bit more masculine; I know that there have been some patients who have said certain things to them that have been discriminating.
 

Have you been especially conscious of how you ‘wear’ your sexual orientation? Have you ever had to change how you’ve presented yourself, lest you have some unpleasant reaction?

I think initially, yes. I would say I’m a little more on the androgynous side with my style. When I was coming out I was trying to figure out where I was and who I was and how I wanted to be, and for the longest time I was dressing more femininely and I wasn’t as comfortable. Since then, I’ve had times where I’ve had short hair or a little bit more of a masculine haircut and wear more masculine clothes and things like that, and I feel much more comfortable doing that.

It’s kind of hard to play the part of a more masculine LGBTQ person at work when you just wear scrubs. I probably don’t portray it as much – I don’t make it as obvious as some other people, but I’ve definitely never shied away from having a conversation with anyone about it.
 

Health care is an intimate profession because of your close interaction with patients and others. Did being a member of the LGBTQ community factor into your decision to enter the health care field, either for or against?

There were times when I didn’t feel well or my mental health was not great because I didn’t know where I was, or hadn’t accepted myself, and I really needed someone who could help me talk through things and try to figure out what my life path was going to be. When I figured those things out with the help of other people, it was life-changing. I respected those people, and that’s what I wanted to do and how I wanted to help. I think that was part of why I got into medicine.

What progress have you seen with regard to LGBTQ health care professionals and patients over the past 5 to 10 years, including subtle changes in culture, attitude, or workplace policies?

Just being interviewed for a profile like this is a step in the right direction. Never once did I think that I would be highlighted for being an LGBTQ person, especially in the workplace.

I think that there are more companies, particularly in health care, and more hospitals that are coming out in support of their LGBTQ employees, especially during Pride month. IU Health walks every year in the Pride parade, which last year was about 3 hours long. Five years previously it was only 30 minutes long. So there are more employers getting involved and recognizing their employees as well. Companies and health care facilities are trying to be more cognizant of their LGBTQ employees and patients and trying to make them more comfortable.
 

What main steps toward more progress would you like to see?

There needs to be greater understanding that people who undergo discrimination actually have more negative health outcomes like heart disease, high blood pressure, and stroke. There needs to be better medical coverage in the LGBTQ community, especially for transgender persons and LGBTQ people who are trying to start families. We need better mental health access, more affordable mental health access, particularly for LGBTQ youth, and we definitely need to continue to raise awareness with hopes that we can eradicate the violence against, and killing of, black transgender persons.

How do you see the Society of Hospital Medicine’s role in this regard?

SHM has a big platform and can certainly reach a lot of people, especially hospitalists who see LGBTQ patients every day. With SHM’s help and the continued training of hospitalists who are members of the society, we can reach out to other clinicians, and to their organizations, and help teach them. SHM really has a good platform to be able to do that, and do it well.

Can you recall a specific interaction with an LGBTQ patient that left you with a potent feeling that “this is what it’s all about”?

I do remember a transgender patient who was homeless. They didn’t have insurance, they couldn’t afford their hormone treatment, and I remember they were struggling with some mental health issues and were “acting out” overnight. Some of the nurses were not using the correct pronouns. I’m more cognizant of their struggles because I’m a member of the LGBTQ community and I was able to recognize this.

I sat down and I talked with the patient for quite a while, we were able to form a bond, and I was able to get a little bit more information from them, and by the end of the night, they felt much better. And just being able to be their voice, when they weren’t able to express exactly how they were feeling, was something that made me thankful that I went into medicine, to help other LGBTQ patients.

I’ve had many LGBTQ patients in the hospital whom I’ve been able to form a bit of a bond with, just knowing that the patient could be me.

Sarah Jones, PA-C, is a physician assistant on the overnight hospitalist team at Indiana University Health Methodist Hospital in Indianapolis, where she has worked for about 8 years. She studied chemistry and biology as an undergraduate at the University of Indianapolis, and then attended PA school at Butler University in Indianapolis. She came out as lesbian/queer just before PA school. She joined the Society of Hospital Medicine in 2020 and serves on SHM’s Diversity and Inclusion Special Interest Group.

How important is it to you to openly identify as a physician assistant who is a member of the LGBTQ community?

I think it’s important to show other people that I am part of the LGBTQ community and that I’ve been able to overcome obstacles and pursue this career and be successful. I can help other people and be in that role [of mentor], and show people that they can do it, too.

What challenges have you faced because of your sexual orientation in the different stages of your career, from training to practicing as a physician assistant?

When my training started, I was much closer to the time when I came out, so my confidence level was a little bit low. I was much more fearful at that point about how people would view me – if I would be thought of as inferior, or not taken as seriously, or that I wasn’t intelligent. I think over the years I’ve grown into this role and it’s helped me become more confident, because I know who I am now. And it’s not something that definitely defines me but I’m confident that I know medicine, and I know how to treat patients and that confidence has gotten much better.

So far at work, everyone’s been great, all my coworkers have been great. I’ve never once felt that my sexuality was holding anyone back from getting to know me better.
 

Have you heard about the experiences of other LGBTQ clinicians who may not have been as fortunate as you, especially transgender people?

There is just a lot of ignorance around LGBTQ persons and especially transgender persons, because people don’t understand it, they don’t get it. So their first inclination is to not approve of it, or be scared of it, or just automatically think that it’s wrong.

If someone’s sexuality comes across much more “obviously” than that of other people, for example, if there’s a gay man who’s a little more flamboyant, [it could be an issue for some patients]. I know there are some gay male nurses who have had patients who don’t want them serving as their nurse, because they’re “obviously” gay. Or a queer woman clinician who has more of an edgier haircut or looks a little bit more masculine; I know that there have been some patients who have said certain things to them that have been discriminating.
 

Have you been especially conscious of how you ‘wear’ your sexual orientation? Have you ever had to change how you’ve presented yourself, lest you have some unpleasant reaction?

I think initially, yes. I would say I’m a little more on the androgynous side with my style. When I was coming out I was trying to figure out where I was and who I was and how I wanted to be, and for the longest time I was dressing more femininely and I wasn’t as comfortable. Since then, I’ve had times where I’ve had short hair or a little bit more of a masculine haircut and wear more masculine clothes and things like that, and I feel much more comfortable doing that.

It’s kind of hard to play the part of a more masculine LGBTQ person at work when you just wear scrubs. I probably don’t portray it as much – I don’t make it as obvious as some other people, but I’ve definitely never shied away from having a conversation with anyone about it.
 

Health care is an intimate profession because of your close interaction with patients and others. Did being a member of the LGBTQ community factor into your decision to enter the health care field, either for or against?

There were times when I didn’t feel well or my mental health was not great because I didn’t know where I was, or hadn’t accepted myself, and I really needed someone who could help me talk through things and try to figure out what my life path was going to be. When I figured those things out with the help of other people, it was life-changing. I respected those people, and that’s what I wanted to do and how I wanted to help. I think that was part of why I got into medicine.

What progress have you seen with regard to LGBTQ health care professionals and patients over the past 5 to 10 years, including subtle changes in culture, attitude, or workplace policies?

Just being interviewed for a profile like this is a step in the right direction. Never once did I think that I would be highlighted for being an LGBTQ person, especially in the workplace.

I think that there are more companies, particularly in health care, and more hospitals that are coming out in support of their LGBTQ employees, especially during Pride month. IU Health walks every year in the Pride parade, which last year was about 3 hours long. Five years previously it was only 30 minutes long. So there are more employers getting involved and recognizing their employees as well. Companies and health care facilities are trying to be more cognizant of their LGBTQ employees and patients and trying to make them more comfortable.
 

What main steps toward more progress would you like to see?

There needs to be greater understanding that people who undergo discrimination actually have more negative health outcomes like heart disease, high blood pressure, and stroke. There needs to be better medical coverage in the LGBTQ community, especially for transgender persons and LGBTQ people who are trying to start families. We need better mental health access, more affordable mental health access, particularly for LGBTQ youth, and we definitely need to continue to raise awareness with hopes that we can eradicate the violence against, and killing of, black transgender persons.

How do you see the Society of Hospital Medicine’s role in this regard?

SHM has a big platform and can certainly reach a lot of people, especially hospitalists who see LGBTQ patients every day. With SHM’s help and the continued training of hospitalists who are members of the society, we can reach out to other clinicians, and to their organizations, and help teach them. SHM really has a good platform to be able to do that, and do it well.

Can you recall a specific interaction with an LGBTQ patient that left you with a potent feeling that “this is what it’s all about”?

I do remember a transgender patient who was homeless. They didn’t have insurance, they couldn’t afford their hormone treatment, and I remember they were struggling with some mental health issues and were “acting out” overnight. Some of the nurses were not using the correct pronouns. I’m more cognizant of their struggles because I’m a member of the LGBTQ community and I was able to recognize this.

I sat down and I talked with the patient for quite a while, we were able to form a bond, and I was able to get a little bit more information from them, and by the end of the night, they felt much better. And just being able to be their voice, when they weren’t able to express exactly how they were feeling, was something that made me thankful that I went into medicine, to help other LGBTQ patients.

I’ve had many LGBTQ patients in the hospital whom I’ve been able to form a bit of a bond with, just knowing that the patient could be me.

Keshav Khanijow, MD, is a hospitalist at Northwestern Memorial Hospital and assistant professor at Northwestern University, Chicago. Originally from the San Francisco Bay area, he studied anthropology as an undergrad at Johns Hopkins University, Baltimore, then went to medical school at the University of California, San Francisco, followed by internal medicine residency and a hospital medicine fellowship at Johns Hopkins Bayview Medical Center. He came out as gay in 2006 as an undergrad. He is a founding member of the Society of Hospital Medicine’s LGBTQ+ Task Force and is involved with SHM’s Diversity and Inclusion Special Interest Group.

What challenges have you faced because of your sexual orientation in the different stages of your career, from training to now as a practicing physician?

In my early training, there weren’t a lot of accessible LGBTQ role models to talk about balancing my personal identities with my professional aspirations. Being a double minority as both South Asian and a gay male, made it that much more difficult. “What is it like to work in health care as a gay cismale? Will being out on my personal statement affect my entry into medical school? Should I list my LGBTQ activism activities or not?” Those were important to me.

And did you make your activism known?

Thankfully, I did. I joke that my application might as well have been printed on rainbow paper, if you will. I decided to be out because I wanted to be part of an environment that would accept me for who I was. But it was a difficult decision.

In medical school at UCSF, it’s San Francisco, so they were a little ahead of the game. They had a lot of social networking opportunities with LGBTQ and ally faculty. Those connections were important in helping me explore different fields, and I even got to write my first publication. That said, networking could sometimes be challenging, especially when it came to residency interviews. While many people would talk about family activities and engagements, I’d only been out to my family for a few years. As such, there would be somewhat of a disconnect. On the flip side, there were LGBTQ celebrations and cultural concepts important to me, but I couldn’t always connect on those fronts either.

When it comes to patients, I do have a bit of a higher-pitched voice, and my mannerisms can be gender nonconforming. While it did make me the target of some cruel middle school humor, I’ve come to be proud of myself, mannerisms and all. That said, I have had patients make remarks to me about being gay, whether it be positive or negative. For LGBTQ patients, they’re like, “this is great, I have a gay doctor. They’ll know a bit more about what I’m talking about or be able to relate to the community pressures I face.”

But sometimes homophobic patients can be a bit more cold. I’ve never had anyone say that they don’t want to have me as their physician, but I definitely have patients who disagree with me and say, essentially, “oh well, you don’t know what you’re talking about because you’re gay.” Of course, there have also been comments based on my ethnicity as well.
 

What specific progress could you point to that you’ve seen over the course of your training and your career so far with regard to LGBTQ health care workers’ experience and LGBTQ patients?

When I was in college, there was a case in 2007 where a woman wasn’t able to see her partner or children before dying in a Florida hospital. Since then, there’s been great strides with a 2011 executive order extending hospital visitation rights to LGBTQ families. In 2013, there was the legalization of same-sex marriage. More recently, in June 2020, the Supreme Court extended protections against workplace discrimination to LGBTQ employees.

But there are certain things that continue to be problems, such as the recent Final Rule from the Department of Health & Human Services that fails to protect our LGBTQ patients and friends against discrimination in health care.
 

Can you remember a specific episode with a patient who was in the LGBTQ community that was particularly satisfying or moving?

There are two that I think about. In medical school, I was working in a more conservative area of California, and there was a patient who identified as lesbian. She felt more able to talk about her fears of raising a family in a conservative area. She even said, “I feel you can understand the stuff, I can talk to you a bit more about it freely, which is really nice.” Later on, I was able to see them on another rotation I was on, after she’d had a baby with her partner. I was honored that they considered me a part of their family’s journey.

A couple years ago as an attending hospitalist, I had a gay male patient that came in for hepatitis A treatment. Although we typically think of hepatitis A as a foodborne illness, oral-anal sex (rimming) is also a risk factor. After having an open discussion with him about his sexual practices, I said, “it was probably an STI in your case,” and was able to give him guidelines on how to prevent giving it to anyone else during the recovery period. He was very appreciative, and I was glad to have been there for that patient.
 

What is SHM’s role in regard to improving the care of LGBTQ patients, improving inclusiveness for LGBTQ health professionals?

Continuing to have educational activities, whether it be lectures at the annual conference or online learning modules, will be critical to care for our LGBTQ patients. With regard to membership, we need to make sure that hospitalists feel included and protected. To this end, our Diversity and Inclusion Special Interest Group was working toward having gender-neutral bathrooms and personal pronoun tags for the in-person 2020 annual conference before it was converted to an online format.

Does it ever get tiring for you to work on “social issues” in addition to strictly medical issues?

I will say I definitely experienced a moment in time during residency where I had to take a step back and recenter myself. Sometimes, realizing how much work needs to get done, coupled with the challenges of one’s personal life, can be daunting. That said, I can only stare at a problem so long before needing to work on creating a solution. At the end of the day I didn’t want to run away from these newfound problems of exclusion – I wanted to be a part of the solution.

In my hospital medicine fellowship, I was lucky to have Flora Kisuule, MD, as a mentor who encouraged me to take my prior work with LGBTQ health and leverage it into hospital medicine projects. As such, I was able to combine a topic I was passionate about with my interests in research and teaching so that they work synergistically. After all, the social issues affect our medical histories, just as our medical issues affect our social being. They go hand in hand.

Keshav Khanijow, MD, is a hospitalist at Northwestern Memorial Hospital and assistant professor at Northwestern University, Chicago. Originally from the San Francisco Bay area, he studied anthropology as an undergrad at Johns Hopkins University, Baltimore, then went to medical school at the University of California, San Francisco, followed by internal medicine residency and a hospital medicine fellowship at Johns Hopkins Bayview Medical Center. He came out as gay in 2006 as an undergrad. He is a founding member of the Society of Hospital Medicine’s LGBTQ+ Task Force and is involved with SHM’s Diversity and Inclusion Special Interest Group.

What challenges have you faced because of your sexual orientation in the different stages of your career, from training to now as a practicing physician?

In my early training, there weren’t a lot of accessible LGBTQ role models to talk about balancing my personal identities with my professional aspirations. Being a double minority as both South Asian and a gay male, made it that much more difficult. “What is it like to work in health care as a gay cismale? Will being out on my personal statement affect my entry into medical school? Should I list my LGBTQ activism activities or not?” Those were important to me.

And did you make your activism known?

Thankfully, I did. I joke that my application might as well have been printed on rainbow paper, if you will. I decided to be out because I wanted to be part of an environment that would accept me for who I was. But it was a difficult decision.

In medical school at UCSF, it’s San Francisco, so they were a little ahead of the game. They had a lot of social networking opportunities with LGBTQ and ally faculty. Those connections were important in helping me explore different fields, and I even got to write my first publication. That said, networking could sometimes be challenging, especially when it came to residency interviews. While many people would talk about family activities and engagements, I’d only been out to my family for a few years. As such, there would be somewhat of a disconnect. On the flip side, there were LGBTQ celebrations and cultural concepts important to me, but I couldn’t always connect on those fronts either.

When it comes to patients, I do have a bit of a higher-pitched voice, and my mannerisms can be gender nonconforming. While it did make me the target of some cruel middle school humor, I’ve come to be proud of myself, mannerisms and all. That said, I have had patients make remarks to me about being gay, whether it be positive or negative. For LGBTQ patients, they’re like, “this is great, I have a gay doctor. They’ll know a bit more about what I’m talking about or be able to relate to the community pressures I face.”

But sometimes homophobic patients can be a bit more cold. I’ve never had anyone say that they don’t want to have me as their physician, but I definitely have patients who disagree with me and say, essentially, “oh well, you don’t know what you’re talking about because you’re gay.” Of course, there have also been comments based on my ethnicity as well.
 

What specific progress could you point to that you’ve seen over the course of your training and your career so far with regard to LGBTQ health care workers’ experience and LGBTQ patients?

When I was in college, there was a case in 2007 where a woman wasn’t able to see her partner or children before dying in a Florida hospital. Since then, there’s been great strides with a 2011 executive order extending hospital visitation rights to LGBTQ families. In 2013, there was the legalization of same-sex marriage. More recently, in June 2020, the Supreme Court extended protections against workplace discrimination to LGBTQ employees.

But there are certain things that continue to be problems, such as the recent Final Rule from the Department of Health & Human Services that fails to protect our LGBTQ patients and friends against discrimination in health care.
 

Can you remember a specific episode with a patient who was in the LGBTQ community that was particularly satisfying or moving?

There are two that I think about. In medical school, I was working in a more conservative area of California, and there was a patient who identified as lesbian. She felt more able to talk about her fears of raising a family in a conservative area. She even said, “I feel you can understand the stuff, I can talk to you a bit more about it freely, which is really nice.” Later on, I was able to see them on another rotation I was on, after she’d had a baby with her partner. I was honored that they considered me a part of their family’s journey.

A couple years ago as an attending hospitalist, I had a gay male patient that came in for hepatitis A treatment. Although we typically think of hepatitis A as a foodborne illness, oral-anal sex (rimming) is also a risk factor. After having an open discussion with him about his sexual practices, I said, “it was probably an STI in your case,” and was able to give him guidelines on how to prevent giving it to anyone else during the recovery period. He was very appreciative, and I was glad to have been there for that patient.
 

What is SHM’s role in regard to improving the care of LGBTQ patients, improving inclusiveness for LGBTQ health professionals?

Continuing to have educational activities, whether it be lectures at the annual conference or online learning modules, will be critical to care for our LGBTQ patients. With regard to membership, we need to make sure that hospitalists feel included and protected. To this end, our Diversity and Inclusion Special Interest Group was working toward having gender-neutral bathrooms and personal pronoun tags for the in-person 2020 annual conference before it was converted to an online format.

Does it ever get tiring for you to work on “social issues” in addition to strictly medical issues?

I will say I definitely experienced a moment in time during residency where I had to take a step back and recenter myself. Sometimes, realizing how much work needs to get done, coupled with the challenges of one’s personal life, can be daunting. That said, I can only stare at a problem so long before needing to work on creating a solution. At the end of the day I didn’t want to run away from these newfound problems of exclusion – I wanted to be a part of the solution.

In my hospital medicine fellowship, I was lucky to have Flora Kisuule, MD, as a mentor who encouraged me to take my prior work with LGBTQ health and leverage it into hospital medicine projects. As such, I was able to combine a topic I was passionate about with my interests in research and teaching so that they work synergistically. After all, the social issues affect our medical histories, just as our medical issues affect our social being. They go hand in hand.

Keshav Khanijow, MD, is a hospitalist at Northwestern Memorial Hospital and assistant professor at Northwestern University, Chicago. Originally from the San Francisco Bay area, he studied anthropology as an undergrad at Johns Hopkins University, Baltimore, then went to medical school at the University of California, San Francisco, followed by internal medicine residency and a hospital medicine fellowship at Johns Hopkins Bayview Medical Center. He came out as gay in 2006 as an undergrad. He is a founding member of the Society of Hospital Medicine’s LGBTQ+ Task Force and is involved with SHM’s Diversity and Inclusion Special Interest Group.

What challenges have you faced because of your sexual orientation in the different stages of your career, from training to now as a practicing physician?

In my early training, there weren’t a lot of accessible LGBTQ role models to talk about balancing my personal identities with my professional aspirations. Being a double minority as both South Asian and a gay male, made it that much more difficult. “What is it like to work in health care as a gay cismale? Will being out on my personal statement affect my entry into medical school? Should I list my LGBTQ activism activities or not?” Those were important to me.

And did you make your activism known?

Thankfully, I did. I joke that my application might as well have been printed on rainbow paper, if you will. I decided to be out because I wanted to be part of an environment that would accept me for who I was. But it was a difficult decision.

In medical school at UCSF, it’s San Francisco, so they were a little ahead of the game. They had a lot of social networking opportunities with LGBTQ and ally faculty. Those connections were important in helping me explore different fields, and I even got to write my first publication. That said, networking could sometimes be challenging, especially when it came to residency interviews. While many people would talk about family activities and engagements, I’d only been out to my family for a few years. As such, there would be somewhat of a disconnect. On the flip side, there were LGBTQ celebrations and cultural concepts important to me, but I couldn’t always connect on those fronts either.

When it comes to patients, I do have a bit of a higher-pitched voice, and my mannerisms can be gender nonconforming. While it did make me the target of some cruel middle school humor, I’ve come to be proud of myself, mannerisms and all. That said, I have had patients make remarks to me about being gay, whether it be positive or negative. For LGBTQ patients, they’re like, “this is great, I have a gay doctor. They’ll know a bit more about what I’m talking about or be able to relate to the community pressures I face.”

But sometimes homophobic patients can be a bit more cold. I’ve never had anyone say that they don’t want to have me as their physician, but I definitely have patients who disagree with me and say, essentially, “oh well, you don’t know what you’re talking about because you’re gay.” Of course, there have also been comments based on my ethnicity as well.
 

What specific progress could you point to that you’ve seen over the course of your training and your career so far with regard to LGBTQ health care workers’ experience and LGBTQ patients?

When I was in college, there was a case in 2007 where a woman wasn’t able to see her partner or children before dying in a Florida hospital. Since then, there’s been great strides with a 2011 executive order extending hospital visitation rights to LGBTQ families. In 2013, there was the legalization of same-sex marriage. More recently, in June 2020, the Supreme Court extended protections against workplace discrimination to LGBTQ employees.

But there are certain things that continue to be problems, such as the recent Final Rule from the Department of Health & Human Services that fails to protect our LGBTQ patients and friends against discrimination in health care.
 

Can you remember a specific episode with a patient who was in the LGBTQ community that was particularly satisfying or moving?

There are two that I think about. In medical school, I was working in a more conservative area of California, and there was a patient who identified as lesbian. She felt more able to talk about her fears of raising a family in a conservative area. She even said, “I feel you can understand the stuff, I can talk to you a bit more about it freely, which is really nice.” Later on, I was able to see them on another rotation I was on, after she’d had a baby with her partner. I was honored that they considered me a part of their family’s journey.

A couple years ago as an attending hospitalist, I had a gay male patient that came in for hepatitis A treatment. Although we typically think of hepatitis A as a foodborne illness, oral-anal sex (rimming) is also a risk factor. After having an open discussion with him about his sexual practices, I said, “it was probably an STI in your case,” and was able to give him guidelines on how to prevent giving it to anyone else during the recovery period. He was very appreciative, and I was glad to have been there for that patient.
 

What is SHM’s role in regard to improving the care of LGBTQ patients, improving inclusiveness for LGBTQ health professionals?

Continuing to have educational activities, whether it be lectures at the annual conference or online learning modules, will be critical to care for our LGBTQ patients. With regard to membership, we need to make sure that hospitalists feel included and protected. To this end, our Diversity and Inclusion Special Interest Group was working toward having gender-neutral bathrooms and personal pronoun tags for the in-person 2020 annual conference before it was converted to an online format.

Does it ever get tiring for you to work on “social issues” in addition to strictly medical issues?

I will say I definitely experienced a moment in time during residency where I had to take a step back and recenter myself. Sometimes, realizing how much work needs to get done, coupled with the challenges of one’s personal life, can be daunting. That said, I can only stare at a problem so long before needing to work on creating a solution. At the end of the day I didn’t want to run away from these newfound problems of exclusion – I wanted to be a part of the solution.

In my hospital medicine fellowship, I was lucky to have Flora Kisuule, MD, as a mentor who encouraged me to take my prior work with LGBTQ health and leverage it into hospital medicine projects. As such, I was able to combine a topic I was passionate about with my interests in research and teaching so that they work synergistically. After all, the social issues affect our medical histories, just as our medical issues affect our social being. They go hand in hand.

In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.

The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.

“I was wondering what was going to happen and who would provide care to this patient?” she said.

Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.

The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.

To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
 

Responding to discrimination

A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.

Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.

“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”

Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.

“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”

Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”

“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.

“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.

Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.

One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.

Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.

“This takes time, and in a busy setting, that might not happen,” she acknowledged.

Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.

An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.

Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”

“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
 

Taking action

Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.

When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.

Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.

“The feedback we received was massive and detailed,” Dr. Polimera said.

Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.

“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”

As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.

Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.

Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.

“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
 

Adapting to change

While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.

Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.

Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.

“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”

Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.

“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”

Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.

In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.

The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.

“I was wondering what was going to happen and who would provide care to this patient?” she said.

Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.

The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.

To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
 

Responding to discrimination

A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.

Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.

“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”

Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.

“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”

Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”

“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.

“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.

Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.

One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.

Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.

“This takes time, and in a busy setting, that might not happen,” she acknowledged.

Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.

An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.

Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”

“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
 

Taking action

Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.

When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.

Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.

“The feedback we received was massive and detailed,” Dr. Polimera said.

Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.

“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”

As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.

Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.

Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.

“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
 

Adapting to change

While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.

Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.

Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.

“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”

Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.

“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”

Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.

In the fall of 2016, Hyma Polimera, MD, a hospitalist at Penn State Health in Hershey, Pa., approached the bedside of a patient with dementia and several other chronic conditions, and introduced herself to him and his family.

The patient’s daughter, who had power of attorney, took one look at Dr. Polimera and told her, “I’d like to see an American doctor.” Dr. Polimera is originally from India, but moved to Europe in 2005 and did her residency in Pennsylvania. She stayed calm and confident – she understood that she had done nothing wrong – but didn’t really know what to do next. All of the other hospitalists on the ward at the time were nonwhite and were also rejected by the patient’s daughter.

“I was wondering what was going to happen and who would provide care to this patient?” she said.

Dr. Polimera is far from alone. Nonwhite physicians, nurses, and other health care providers say they increasingly encounter patients who demand that only “white” health professionals take care of them. The number of these reassignment requests has ticked upward in the last few years, they say, coinciding with the 2016 U.S. presidential campaign and the subsequent election of Donald Trump.

The requests often come at medical centers with no policy in place for how to deal with them. And the unpleasant encounters find providers unprepared for how to respond, not knowing whether or how to resolve the situation with patients and their families. Clinicians sometimes wonder whether they are allowed to care for a patient even if they are willing to do so, and how to go about reassigning a patient to another clinician if that is the choice that the family makes.

To many hospitalists working in the field, it seems obvious that such situations are encouraged by a political environment in which discriminatory beliefs – once considered shameful to express publicly – are now deemed acceptable, even in health care encounters. Indeed, the health care encounter is perhaps the only time some patients will find themselves in intimate interactions with people of other ethnicities.
 

Responding to discrimination

A workshop at the 2019 Society of Hospital Medicine Annual Conference offered hospitalists an opportunity to discuss encounters with patients who expressed discriminatory attitudes. One physician, of South Asian descent, said that she had encountered no reassignment requests rooted in racial intolerance over more than a decade of work, but has encountered several in the last year or two.

Sabrina Chaklos, MD, a hospitalist at Burlington, Mass.–based Lahey Hospital & Medical Center and clinical assistant professor at Tufts University, said she has had a similar experience.

“It was blatantly bad behavior for 2018,” she said. Dr. Chaklos said she and other clinicians of color have been told, “I want an American doctor,” and that some patients see her darker complexion and conclude, “You must not be an American.”

Given the charged political environment since 2016, some medical facilities have been adapting how they respond to these comments and requests.

“The policy of the organization prior to 2016 was to give patients a new doctor,” Dr. Chaklos said. “Within the past year or so, they’re finally allowing people to say, ‘Look, you cannot just pick and choose your doctor,’ based on arbitrary reasons that are discriminatory in nature.”

Emily Whitgob, MD, MEd, a developmental-behavioral pediatrician at Santa Clara Valley Medical Center in San Jose, Calif., said that, several years ago, a scenario unfolded that led her to study the issue. An intern she was overseeing told her that the father of a pediatric patient had scrutinized the intern’s name tag and said, “Is that a Jewish last name? I don’t want a Jewish doctor.”

“I didn’t know what to do,” Dr. Whitgob said. Later, she brought up the situation at a meeting of 30 staff members. It led to an outpouring of sharing about similar incidents that other clinicians had experienced but had never talked about with colleagues.

“Half the room, by the end, was in tears talking about their experiences,” Dr. Whitgob said.

Since then, she has led research into how physicians typically handle such situations, performing semistructured interviews to survey pediatricians about their experiences with patients who discriminate on racial and ethnic grounds.

One important step, she said, is assessing the acuity of the illness involved to help determine whether the transfer of a patient from one provider to another should even be considered. In a dire situation, or when the physician involved is the foremost expert on a given condition, it might not be realistic.

Dr. Whitgob said some clinicians advocated cultivating a kind of alliance with the parents of pediatric patients, informing them that they’re part of a team that interacts with many types of providers, and redirecting them to focus on their child’s care.

“This takes time, and in a busy setting, that might not happen,” she acknowledged.

Physicians surveyed also said they try to depersonalize the uncomfortable encounter, remembering that discrimination is often motivated by a patient’s fears and a lack of control.

An important consideration, researchers found, was ensuring a safe learning environment for trainees, telling patients they would trust the physician with the care of their own children, escalating a complaint to hospital administration when appropriate, and empowering trainees to choose the next step in a situation.

Dr. Whitgob said that handling a reassignment request based on discriminatory sentiments is not as easy as “calling out ‘Code Bigotry.’ ”

“It’s not that simple,” Dr. Whitgob said. “There’s not going to be a one-size-fits-all or even a one-size-fits-most solution. Each case is an individual case.”
 

Taking action

Penn State Health is based in Hershey, Pa., a city that tends to vote Democratic in local and national elections but is encircled by Republican-leaning counties. Dr. Polimera’s encounter with her patient’s daughter led to changes in the way the health system handles encounters like hers.

When Dr. Polimera explained the situation to physician leadership, she was asked whether she was still comfortable taking care of the patient, and she said yes. The physician leaders informed the family that they could not change providers simply because of ethnicity. But that was just the first step.

Ultimately, the health system undertook a survey of all its health care providers, to determine whether others had similar experiences with patients or families, and had to deal with rude comments or were rejected as caregivers based on their race, gender, or religion.

“The feedback we received was massive and detailed,” Dr. Polimera said.

Brian McGillen, MD, section chief of hospital medicine and associate professor in the department of medicine at Penn State Health, said physician leaders took the survey results to the dean’s executive council, a who’s-who of medical leadership at the health system.

“I read aloud to the executive council what our folks were facing out on the floors,” Dr. McGillen said. “And I was halfway through my third story when the dean threw his hands up in the air and said, ‘We have to do something.’ ”

As a result, the health system’s policy on patient responsibility was changed to protect all health care providers from threats, violence, disrespectful communication, or harassment by patients, families, and other visitors. Before the change, the policy covered only discriminatory acts by patients themselves.

Penn State Health is now embarking on a training program for faculty, residents, and students that uses simulations of common hospital encounters. The health system also is engaging its patient relations staff to help mediate patient reassignment requests, and is trying to increase real-time debriefing of these events to further improve awareness and training.

Dr. McGillen noted that researchers at the University of North Texas, using data from the Anti-Defamation League, found that counties in which President Trump held campaign rallies – such as Dauphin County, Pa., where Hershey is located – had a 226% increase in hate crimes in the months after the rallies.

“This isn’t to say that every county and every person in these counties that voted for Mr. Trump is racist, but we surely know that his campaign unlocked an undercurrent of political incorrectness that has existed for ages,” he said. “We had to do something as an organization.”
 

Adapting to change

While some health systems are acting to limit the harm caused by discrimination, there is still much awareness to be raised and work to be done on this issue nationally. Some hospitalists at the 2019 SHM Annual Conference said they suspect that discriminatory incidents involving patients are still so underreported that the C-suite leaders at their hospitals do not recognize how serious a problem it is. Attendees at the HM19 workshop said discriminatory behavior by patients could affect hospitalist turnover and lead to burnout.

Multiple hospitalists at the workshop said that if a transfer of a patient is going to take place – if the patient requests a “white” doctor and there is not one available where the patient is admitted – they are unsure whether it is their responsibility to make the necessary phone calls. Some hospitalists say that if that job does fall to them, it interrupts work flow.

Susan Hakes, MHA, director of hospital administration at the Guthrie Clinic in Ithaca, N.Y., said that when a patient recently asked for a “white” doctor and there was not one available at the time of the request, the patient changed her mind when costs were considered.

“I was willing to have this patient transferred to another one of our hospitals that did have a white doctor, but it would have been at her expense since insurance wouldn’t cover the ambulance ride,” Ms. Hakes said. “She had second thoughts after learning that.”

Ms. Hakes said that the broader community in her region – which is predominantly white – needs to adapt to a changing health care scene.

“We’re recruiting international nurses now, due to the nursing shortage,” she said. “It will serve our community well to be receptive and welcome this additional resource.”

Kunal P. Bhagat, MD, chief of hospital medicine at Christiana Care Health System in Newark, Del., said that medical centers should set parameters for action when a patient discriminates, but that clinicians should not expect to fundamentally change a patient’s mindset.

A Vietnam veteran steered clear of the health care system for years, then showed up at the hospital with pneumonia and respiratory failure. He was whisked to the intensive care unit, and cancerous masses were found.

The situation – as described by Jeffrey Frank, MD, director of quality and performance at Vituity, a physician group in Emeryville, Calif. – then got worse.

“No one was there for him,” Dr. Frank said. “He’s laying in the ICU, he does not have the capacity to make decisions, let alone communicate. So the care team needs guidance.”

Too often, hospitalists find themselves in confusing situations involving patients near the end of their lives, having to determine how to go about treating a patient or withholding treatment when patients are not in a position to announce their wishes. When family is present, the health care team thinks the most sensible course of treatment is at odds with what the family wants to be done.

At the Society of Hospital Medicine 2019 Annual Conference, hospitalists with palliative care training offered advice on how to go about handling these difficult situations, which can sometimes become more manageable with certain strategies.

For situations in which there is no designated representative to speak for a patient who is unresponsive – the so-called “unbefriended patient” or “unrepresented patient” – any source of information can be valuable. And health care providers should seek out this input, Dr. Frank said.

“When there is a visitor at the bedside, and as long as they know the person, and they can start giving the medical providers some information about what the patient would have wanted, most of us will talk with that person and that’s actually a good habit,” he said.

Thirty-nine states and the District of Columbia have regulations on whom health care providers should talk to when there is no obvious representative, Dr. Frank said, noting that most of these regulations follow a classic family-tree order. But in the discouraging results of many surveys of health care providers on the subject, most clinicians say that they do not know the regulations in their state, Dr. Frank said. But he said such results betray a silver lining because clinicians say that they would be inclined to use a family tree–style hierarchy in deciding with whom they should speak about end of life decisions.

Hospitalists should at least know whether their hospital has a policy on unrepresented patients, Dr. Frank said.

“That’s your road map on how to get through consenting this patient – what am I going to do with Mr. Smith?” he said. “You may ask yourself, ‘Do I just keep treating him and treating him?’ If you have a policy at your hospital, it will protect you from liability, as well as give you a sense of process.”
 

Conflicts in communication

An even worse situation, perhaps, is one that many hospitalists have seen: A patient is teetering at the edge of life, and a spouse arrives, along with two daughters from out of state who have not seen their father in a year, said Elizabeth Gundersen, MD, director of the ethics curriculum at Florida Atlantic University, Boca Raton.

“The family requests that the medical team do everything, including intubation and attempts at resuscitation if needed,” she said. “The family says he was fine prior to this admission. Another thing I hear a lot is, ‘He was even sicker than this last year, and he got better.’ ”

Meanwhile, “the medical team consensus is that he is not going to survive this illness,” Dr. Gundersen said.

The situation is so common and problematic that it has a name – the “Daughter from California Syndrome.” (According to medical literature says, it’s called the “Daughter from Chicago Syndrome” in California.)

“This is one of the most agonizing things that happens to us in medicine,” Dr. Gundersen said. “It affects us, it affects our nurses, it affects the entire medical team. It’s agonizing when we feel like treatment has somehow turned to torture.”

Dr. Gundersen said the medical staff should avoid using the word “futile,” or similar language, with families.

“Words matter,” she said. “Inappropriate language can inadvertently convey the feeling that, ‘They’re giving up on my dad – they think it’s hopeless.’ That can make families and the medical team dig in their heels further.”

Sometimes it can be hard to define the terms of decision making. Even if the family and the medical team can agree that no “nonbeneficial treatments” should be administered, Dr. Gundersen said, what exactly does that mean? Does it mean less than a 1% chance of working; less than a 5% chance?

If the medical staff thinks a mode of care won’t be effective, but the family still insists, some states have laws that could help the medical team. In Texas, for example, if the medical team thinks the care they’re giving isn’t helping the patient, and the patient is likely going to have a poor outcome, there’s a legal process that the team can go through, Dr. Gundersen said. But even these laws are seen as potentially problematic because of concerns that they put too much power in the hands of a hospital committee.

Dr. Gundersen strongly advised getting at the root causes of a family’s apprehension. They might not have been informed early enough about the dire nature of an illness to feel they can make a decision comfortably. They also may be receiving information in a piecemeal manner or information that is inconsistent. Another common fear expressed by families is a concern over abandonment by the medical team if a decision is made to forgo a certain treatment. Also, sometimes the goals of care might not be properly detailed and discussed, she said.

But better communication can help overcome these snags, Dr. Gundersen said.

She suggested that sometimes it’s helpful to clarify things with the family, for example, what do they mean by “Do everything”?

“Does it mean ‘I want you to do everything to prolong their life even if they suffer,’ or does it mean ‘I want you do to everything that’s reasonable to try to prolong their life but not at the risk of increased suffering,’ or anywhere in between. Really just having these clarifying conversations is helpful.”

She also emphasized the importance of talking about interests, such as not wanting a patient to suffer, instead of taking positions, such as flatly recommending the withdrawal of treatment.

“It’s easy for both sides to kind of dig in their heels and not communicate effectively,” Dr. Gundersen said.
 

‘Emotional torture’

There are times when, no matter how skillfully the medical team communicates, they stand at an impasse with the family.

“This is emotional torture for us,” Dr. Gundersen said. “It’s moral distress. We kind of dread these situations. In these cases, trying to support yourself and your team emotionally is the most important thing.”

Ami Doshi, MD, director of palliative care inpatient services at Rady Children’s Hospital in San Diego, described the case of a baby girl that touched on the especially painful issues that can arise in pediatric cases. The 2-month-old girl had been born after a pregnancy affected by polyhydramnios and had an abnormal neurological exam and brain MRI, as well as congenital abnormalities. She’d been intubated for respiratory failure and was now on high-flow nasal cannula therapy. The girl was intolerant to feeding and was put on a nasojejunal feeding tube and then a gastrostomy-jejunostomy tube.

But the baby’s vomiting continued, and she had bradycardia and hypoxia so severe she needed bag mask ventilation to recover. The mother started to feel like she was “torturing” the baby.

The family decided to stop respiratory support but to continue artificial nutrition and hydration, which Dr. Doshi said, has an elevated status in the human psyche. Mentioning discontinuing feeding is fraught with complexity, she said.

“The notion of feeding is such a basic instinct, especially with a baby, that tackling the notion of discontinuing any sort of feeds, orally or tube feeds, is fraught with emotion and angst at times,” Dr. Doshi said.

The girl had respiratory events but recovered from them on her own, but the vomiting and retching continued. Eventually the artificial nutrition and hydration was stopped. But after 5 days, the medical staff began feeling uncomfortable, Dr. Doshi said. “We’re starting to hear from nurses, doctors, other people, that something just doesn’t feel right about what’s happening: ‘She seems okay,’ and, ‘Is it really okay for us to be doing this?’ and ‘Gosh, this is taking a long time.’ ”

The medical staff had, in a sense, joined the family on the emotional roller coaster.

Dr. Doshi said it’s important to remember that there is no ethical or moral distinction between withdrawing a medical intervention and withholding one.

“Stopping an intervention once it has started is no different ethically or legally than not starting it in the first place,” she said.

According to Dr. Doshi, there is a general consensus among medical societies that artificial nutrition and hydration is a medical intervention just like any other and that it should be evaluated within the same framework: Is it overly burdensome? Are we doing harm? Is it consistent with the goal of care? In so doing, be sure to respect patient autonomy and obtain informed consent.

As with so much in medicine, careful communication is a must.

“Paint a picture of what the patient’s trajectory is going to look like with and without artificial nutrition and hydration. At the end of the day, having done all of that, we’re going to ultimately respect what the patient or the surrogate decision maker decides,” Dr. Doshi said.

After assessment the data and the chances of success, and still without clarity about how to proceed, a good option might be considering a “time-limited trial” in which the medical team sits with the family and agrees on a time frame for an intervention and chooses predetermined endpoints for assessing success or failure.

“This can be very powerful to help us understand whether it is beneficial, but also – from the family’s perspective – to know everything was tried,” Dr. Doshi said.

Hospitalists should emphasize what is being added to treatment so that families don’t think only of what is being taken away, she said.

“Usually we are adding a lot – symptom management, a lot of psychosocial support. So what are all the other ways that we’re going to continue to care for the patient, even when we are withdrawing or withholding a specific intervention?” Dr. Doshi noted.

Sometimes, the best healer of distress in the midst of end of life decision making is time itself, Dr. Gundersen said.

In a condolence call, she once spoke with a family member involved in an agonizing case in which the medical team and family were at odds. Yet the man told her: “I know that you all were telling us the entire time that this was going to happen, but I guess we just had to go through our own process.”

A Vietnam veteran steered clear of the health care system for years, then showed up at the hospital with pneumonia and respiratory failure. He was whisked to the intensive care unit, and cancerous masses were found.

The situation – as described by Jeffrey Frank, MD, director of quality and performance at Vituity, a physician group in Emeryville, Calif. – then got worse.

“No one was there for him,” Dr. Frank said. “He’s laying in the ICU, he does not have the capacity to make decisions, let alone communicate. So the care team needs guidance.”

Too often, hospitalists find themselves in confusing situations involving patients near the end of their lives, having to determine how to go about treating a patient or withholding treatment when patients are not in a position to announce their wishes. When family is present, the health care team thinks the most sensible course of treatment is at odds with what the family wants to be done.

At the Society of Hospital Medicine 2019 Annual Conference, hospitalists with palliative care training offered advice on how to go about handling these difficult situations, which can sometimes become more manageable with certain strategies.

For situations in which there is no designated representative to speak for a patient who is unresponsive – the so-called “unbefriended patient” or “unrepresented patient” – any source of information can be valuable. And health care providers should seek out this input, Dr. Frank said.

“When there is a visitor at the bedside, and as long as they know the person, and they can start giving the medical providers some information about what the patient would have wanted, most of us will talk with that person and that’s actually a good habit,” he said.

Thirty-nine states and the District of Columbia have regulations on whom health care providers should talk to when there is no obvious representative, Dr. Frank said, noting that most of these regulations follow a classic family-tree order. But in the discouraging results of many surveys of health care providers on the subject, most clinicians say that they do not know the regulations in their state, Dr. Frank said. But he said such results betray a silver lining because clinicians say that they would be inclined to use a family tree–style hierarchy in deciding with whom they should speak about end of life decisions.

Hospitalists should at least know whether their hospital has a policy on unrepresented patients, Dr. Frank said.

“That’s your road map on how to get through consenting this patient – what am I going to do with Mr. Smith?” he said. “You may ask yourself, ‘Do I just keep treating him and treating him?’ If you have a policy at your hospital, it will protect you from liability, as well as give you a sense of process.”
 

Conflicts in communication

An even worse situation, perhaps, is one that many hospitalists have seen: A patient is teetering at the edge of life, and a spouse arrives, along with two daughters from out of state who have not seen their father in a year, said Elizabeth Gundersen, MD, director of the ethics curriculum at Florida Atlantic University, Boca Raton.

“The family requests that the medical team do everything, including intubation and attempts at resuscitation if needed,” she said. “The family says he was fine prior to this admission. Another thing I hear a lot is, ‘He was even sicker than this last year, and he got better.’ ”

Meanwhile, “the medical team consensus is that he is not going to survive this illness,” Dr. Gundersen said.

The situation is so common and problematic that it has a name – the “Daughter from California Syndrome.” (According to medical literature says, it’s called the “Daughter from Chicago Syndrome” in California.)

“This is one of the most agonizing things that happens to us in medicine,” Dr. Gundersen said. “It affects us, it affects our nurses, it affects the entire medical team. It’s agonizing when we feel like treatment has somehow turned to torture.”

Dr. Gundersen said the medical staff should avoid using the word “futile,” or similar language, with families.

“Words matter,” she said. “Inappropriate language can inadvertently convey the feeling that, ‘They’re giving up on my dad – they think it’s hopeless.’ That can make families and the medical team dig in their heels further.”

Sometimes it can be hard to define the terms of decision making. Even if the family and the medical team can agree that no “nonbeneficial treatments” should be administered, Dr. Gundersen said, what exactly does that mean? Does it mean less than a 1% chance of working; less than a 5% chance?

If the medical staff thinks a mode of care won’t be effective, but the family still insists, some states have laws that could help the medical team. In Texas, for example, if the medical team thinks the care they’re giving isn’t helping the patient, and the patient is likely going to have a poor outcome, there’s a legal process that the team can go through, Dr. Gundersen said. But even these laws are seen as potentially problematic because of concerns that they put too much power in the hands of a hospital committee.

Dr. Gundersen strongly advised getting at the root causes of a family’s apprehension. They might not have been informed early enough about the dire nature of an illness to feel they can make a decision comfortably. They also may be receiving information in a piecemeal manner or information that is inconsistent. Another common fear expressed by families is a concern over abandonment by the medical team if a decision is made to forgo a certain treatment. Also, sometimes the goals of care might not be properly detailed and discussed, she said.

But better communication can help overcome these snags, Dr. Gundersen said.

She suggested that sometimes it’s helpful to clarify things with the family, for example, what do they mean by “Do everything”?

“Does it mean ‘I want you to do everything to prolong their life even if they suffer,’ or does it mean ‘I want you do to everything that’s reasonable to try to prolong their life but not at the risk of increased suffering,’ or anywhere in between. Really just having these clarifying conversations is helpful.”

She also emphasized the importance of talking about interests, such as not wanting a patient to suffer, instead of taking positions, such as flatly recommending the withdrawal of treatment.

“It’s easy for both sides to kind of dig in their heels and not communicate effectively,” Dr. Gundersen said.
 

‘Emotional torture’

There are times when, no matter how skillfully the medical team communicates, they stand at an impasse with the family.

“This is emotional torture for us,” Dr. Gundersen said. “It’s moral distress. We kind of dread these situations. In these cases, trying to support yourself and your team emotionally is the most important thing.”

Ami Doshi, MD, director of palliative care inpatient services at Rady Children’s Hospital in San Diego, described the case of a baby girl that touched on the especially painful issues that can arise in pediatric cases. The 2-month-old girl had been born after a pregnancy affected by polyhydramnios and had an abnormal neurological exam and brain MRI, as well as congenital abnormalities. She’d been intubated for respiratory failure and was now on high-flow nasal cannula therapy. The girl was intolerant to feeding and was put on a nasojejunal feeding tube and then a gastrostomy-jejunostomy tube.

But the baby’s vomiting continued, and she had bradycardia and hypoxia so severe she needed bag mask ventilation to recover. The mother started to feel like she was “torturing” the baby.

The family decided to stop respiratory support but to continue artificial nutrition and hydration, which Dr. Doshi said, has an elevated status in the human psyche. Mentioning discontinuing feeding is fraught with complexity, she said.

“The notion of feeding is such a basic instinct, especially with a baby, that tackling the notion of discontinuing any sort of feeds, orally or tube feeds, is fraught with emotion and angst at times,” Dr. Doshi said.

The girl had respiratory events but recovered from them on her own, but the vomiting and retching continued. Eventually the artificial nutrition and hydration was stopped. But after 5 days, the medical staff began feeling uncomfortable, Dr. Doshi said. “We’re starting to hear from nurses, doctors, other people, that something just doesn’t feel right about what’s happening: ‘She seems okay,’ and, ‘Is it really okay for us to be doing this?’ and ‘Gosh, this is taking a long time.’ ”

The medical staff had, in a sense, joined the family on the emotional roller coaster.

Dr. Doshi said it’s important to remember that there is no ethical or moral distinction between withdrawing a medical intervention and withholding one.

“Stopping an intervention once it has started is no different ethically or legally than not starting it in the first place,” she said.

According to Dr. Doshi, there is a general consensus among medical societies that artificial nutrition and hydration is a medical intervention just like any other and that it should be evaluated within the same framework: Is it overly burdensome? Are we doing harm? Is it consistent with the goal of care? In so doing, be sure to respect patient autonomy and obtain informed consent.

As with so much in medicine, careful communication is a must.

“Paint a picture of what the patient’s trajectory is going to look like with and without artificial nutrition and hydration. At the end of the day, having done all of that, we’re going to ultimately respect what the patient or the surrogate decision maker decides,” Dr. Doshi said.

After assessment the data and the chances of success, and still without clarity about how to proceed, a good option might be considering a “time-limited trial” in which the medical team sits with the family and agrees on a time frame for an intervention and chooses predetermined endpoints for assessing success or failure.

“This can be very powerful to help us understand whether it is beneficial, but also – from the family’s perspective – to know everything was tried,” Dr. Doshi said.

Hospitalists should emphasize what is being added to treatment so that families don’t think only of what is being taken away, she said.

“Usually we are adding a lot – symptom management, a lot of psychosocial support. So what are all the other ways that we’re going to continue to care for the patient, even when we are withdrawing or withholding a specific intervention?” Dr. Doshi noted.

Sometimes, the best healer of distress in the midst of end of life decision making is time itself, Dr. Gundersen said.

In a condolence call, she once spoke with a family member involved in an agonizing case in which the medical team and family were at odds. Yet the man told her: “I know that you all were telling us the entire time that this was going to happen, but I guess we just had to go through our own process.”

A Vietnam veteran steered clear of the health care system for years, then showed up at the hospital with pneumonia and respiratory failure. He was whisked to the intensive care unit, and cancerous masses were found.

The situation – as described by Jeffrey Frank, MD, director of quality and performance at Vituity, a physician group in Emeryville, Calif. – then got worse.

“No one was there for him,” Dr. Frank said. “He’s laying in the ICU, he does not have the capacity to make decisions, let alone communicate. So the care team needs guidance.”

Too often, hospitalists find themselves in confusing situations involving patients near the end of their lives, having to determine how to go about treating a patient or withholding treatment when patients are not in a position to announce their wishes. When family is present, the health care team thinks the most sensible course of treatment is at odds with what the family wants to be done.

At the Society of Hospital Medicine 2019 Annual Conference, hospitalists with palliative care training offered advice on how to go about handling these difficult situations, which can sometimes become more manageable with certain strategies.

For situations in which there is no designated representative to speak for a patient who is unresponsive – the so-called “unbefriended patient” or “unrepresented patient” – any source of information can be valuable. And health care providers should seek out this input, Dr. Frank said.

“When there is a visitor at the bedside, and as long as they know the person, and they can start giving the medical providers some information about what the patient would have wanted, most of us will talk with that person and that’s actually a good habit,” he said.

Thirty-nine states and the District of Columbia have regulations on whom health care providers should talk to when there is no obvious representative, Dr. Frank said, noting that most of these regulations follow a classic family-tree order. But in the discouraging results of many surveys of health care providers on the subject, most clinicians say that they do not know the regulations in their state, Dr. Frank said. But he said such results betray a silver lining because clinicians say that they would be inclined to use a family tree–style hierarchy in deciding with whom they should speak about end of life decisions.

Hospitalists should at least know whether their hospital has a policy on unrepresented patients, Dr. Frank said.

“That’s your road map on how to get through consenting this patient – what am I going to do with Mr. Smith?” he said. “You may ask yourself, ‘Do I just keep treating him and treating him?’ If you have a policy at your hospital, it will protect you from liability, as well as give you a sense of process.”
 

Conflicts in communication

An even worse situation, perhaps, is one that many hospitalists have seen: A patient is teetering at the edge of life, and a spouse arrives, along with two daughters from out of state who have not seen their father in a year, said Elizabeth Gundersen, MD, director of the ethics curriculum at Florida Atlantic University, Boca Raton.

“The family requests that the medical team do everything, including intubation and attempts at resuscitation if needed,” she said. “The family says he was fine prior to this admission. Another thing I hear a lot is, ‘He was even sicker than this last year, and he got better.’ ”

Meanwhile, “the medical team consensus is that he is not going to survive this illness,” Dr. Gundersen said.

The situation is so common and problematic that it has a name – the “Daughter from California Syndrome.” (According to medical literature says, it’s called the “Daughter from Chicago Syndrome” in California.)

“This is one of the most agonizing things that happens to us in medicine,” Dr. Gundersen said. “It affects us, it affects our nurses, it affects the entire medical team. It’s agonizing when we feel like treatment has somehow turned to torture.”

Dr. Gundersen said the medical staff should avoid using the word “futile,” or similar language, with families.

“Words matter,” she said. “Inappropriate language can inadvertently convey the feeling that, ‘They’re giving up on my dad – they think it’s hopeless.’ That can make families and the medical team dig in their heels further.”

Sometimes it can be hard to define the terms of decision making. Even if the family and the medical team can agree that no “nonbeneficial treatments” should be administered, Dr. Gundersen said, what exactly does that mean? Does it mean less than a 1% chance of working; less than a 5% chance?

If the medical staff thinks a mode of care won’t be effective, but the family still insists, some states have laws that could help the medical team. In Texas, for example, if the medical team thinks the care they’re giving isn’t helping the patient, and the patient is likely going to have a poor outcome, there’s a legal process that the team can go through, Dr. Gundersen said. But even these laws are seen as potentially problematic because of concerns that they put too much power in the hands of a hospital committee.

Dr. Gundersen strongly advised getting at the root causes of a family’s apprehension. They might not have been informed early enough about the dire nature of an illness to feel they can make a decision comfortably. They also may be receiving information in a piecemeal manner or information that is inconsistent. Another common fear expressed by families is a concern over abandonment by the medical team if a decision is made to forgo a certain treatment. Also, sometimes the goals of care might not be properly detailed and discussed, she said.

But better communication can help overcome these snags, Dr. Gundersen said.

She suggested that sometimes it’s helpful to clarify things with the family, for example, what do they mean by “Do everything”?

“Does it mean ‘I want you to do everything to prolong their life even if they suffer,’ or does it mean ‘I want you do to everything that’s reasonable to try to prolong their life but not at the risk of increased suffering,’ or anywhere in between. Really just having these clarifying conversations is helpful.”

She also emphasized the importance of talking about interests, such as not wanting a patient to suffer, instead of taking positions, such as flatly recommending the withdrawal of treatment.

“It’s easy for both sides to kind of dig in their heels and not communicate effectively,” Dr. Gundersen said.
 

‘Emotional torture’

There are times when, no matter how skillfully the medical team communicates, they stand at an impasse with the family.

“This is emotional torture for us,” Dr. Gundersen said. “It’s moral distress. We kind of dread these situations. In these cases, trying to support yourself and your team emotionally is the most important thing.”

Ami Doshi, MD, director of palliative care inpatient services at Rady Children’s Hospital in San Diego, described the case of a baby girl that touched on the especially painful issues that can arise in pediatric cases. The 2-month-old girl had been born after a pregnancy affected by polyhydramnios and had an abnormal neurological exam and brain MRI, as well as congenital abnormalities. She’d been intubated for respiratory failure and was now on high-flow nasal cannula therapy. The girl was intolerant to feeding and was put on a nasojejunal feeding tube and then a gastrostomy-jejunostomy tube.

But the baby’s vomiting continued, and she had bradycardia and hypoxia so severe she needed bag mask ventilation to recover. The mother started to feel like she was “torturing” the baby.

The family decided to stop respiratory support but to continue artificial nutrition and hydration, which Dr. Doshi said, has an elevated status in the human psyche. Mentioning discontinuing feeding is fraught with complexity, she said.

“The notion of feeding is such a basic instinct, especially with a baby, that tackling the notion of discontinuing any sort of feeds, orally or tube feeds, is fraught with emotion and angst at times,” Dr. Doshi said.

The girl had respiratory events but recovered from them on her own, but the vomiting and retching continued. Eventually the artificial nutrition and hydration was stopped. But after 5 days, the medical staff began feeling uncomfortable, Dr. Doshi said. “We’re starting to hear from nurses, doctors, other people, that something just doesn’t feel right about what’s happening: ‘She seems okay,’ and, ‘Is it really okay for us to be doing this?’ and ‘Gosh, this is taking a long time.’ ”

The medical staff had, in a sense, joined the family on the emotional roller coaster.

Dr. Doshi said it’s important to remember that there is no ethical or moral distinction between withdrawing a medical intervention and withholding one.

“Stopping an intervention once it has started is no different ethically or legally than not starting it in the first place,” she said.

According to Dr. Doshi, there is a general consensus among medical societies that artificial nutrition and hydration is a medical intervention just like any other and that it should be evaluated within the same framework: Is it overly burdensome? Are we doing harm? Is it consistent with the goal of care? In so doing, be sure to respect patient autonomy and obtain informed consent.

As with so much in medicine, careful communication is a must.

“Paint a picture of what the patient’s trajectory is going to look like with and without artificial nutrition and hydration. At the end of the day, having done all of that, we’re going to ultimately respect what the patient or the surrogate decision maker decides,” Dr. Doshi said.

After assessment the data and the chances of success, and still without clarity about how to proceed, a good option might be considering a “time-limited trial” in which the medical team sits with the family and agrees on a time frame for an intervention and chooses predetermined endpoints for assessing success or failure.

“This can be very powerful to help us understand whether it is beneficial, but also – from the family’s perspective – to know everything was tried,” Dr. Doshi said.

Hospitalists should emphasize what is being added to treatment so that families don’t think only of what is being taken away, she said.

“Usually we are adding a lot – symptom management, a lot of psychosocial support. So what are all the other ways that we’re going to continue to care for the patient, even when we are withdrawing or withholding a specific intervention?” Dr. Doshi noted.

Sometimes, the best healer of distress in the midst of end of life decision making is time itself, Dr. Gundersen said.

In a condolence call, she once spoke with a family member involved in an agonizing case in which the medical team and family were at odds. Yet the man told her: “I know that you all were telling us the entire time that this was going to happen, but I guess we just had to go through our own process.”

Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.

The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”

“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”

Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.

“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”

Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
 

Scheduling problems

The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).

A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.

Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.

Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.

“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”

Dr. Michtalik had a similar perspective.

“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”

Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.

In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.

Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.

Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.

“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
 

Beyond salary adjustments

Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.

Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.

The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.

A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.

Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.

Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”

“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.

“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.

If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”

Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”

Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.

She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.

At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.

“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.

As a result, a collaborative approach to such conversations tends to be more effective.

“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”

Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.

The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”

“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”

Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.

“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”

Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
 

Scheduling problems

The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).

A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.

Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.

Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.

“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”

Dr. Michtalik had a similar perspective.

“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”

Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.

In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.

Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.

Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.

“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
 

Beyond salary adjustments

Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.

Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.

The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.

A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.

Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.

Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”

“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.

“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.

If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”

Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”

Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.

She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.

At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.

“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.

As a result, a collaborative approach to such conversations tends to be more effective.

“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”

Hospitalist Rahul C. Borsadia, MD, had been working with Orlando Health Inpatient Medicine Group since the year of its founding in 2011.

The salaries of the practice’s physicians back then were based on relative value units (RVU) – the more patients that physicians saw, the higher their salaries. But a problem arose, Dr. Borsadia said. Physicians were trying to squeeze in two dozen or more patients a day “in a practice that is modeled for quality.”

“By the time the end of the day comes, it’s 9 or 10 p.m. and you are leaving but coming back at 6:30 the next morning. So, lack of sleep, more patients, striving to earn that higher salary,” he said. “The desire to perform quality work with that kind of patient load was not fulfilled and that lead to dissatisfaction and stress, which lead to irritation and exodus from the group.”

Three years ago, the practice transitioned to a throughput process with a census limit of 18 patients or less, without an RVU system, but with salary incentives based on patient satisfaction, billing, and documentation.

“We’ve not had anybody leave the hospital because of burnout or dissatisfaction” since the new system was put into place, Dr. Borsadia said. “Less burnout means more people are happy.”

Although symptoms of burnout still seem to be rampant across hospital medicine, hospitalists are putting potential solutions into place. And – sometimes – they are making progress, through tweaks in schedules and responsibilities, incentives suited to different goals, and better communication.
 

Scheduling problems

The need for continuing efforts to improve the work experience for hospitalists is apparent, said Henry Michtalik, MD, MPH, MHS, assistant professor of general internal medicine at Johns Hopkins, Baltimore, who led a workshop on the topic at the 2019 Annual Conference of the Society of Hospital Medicine (HM19).

A 2016 survey of academic general internal medicine clinicians – including about 600 hospitalists and outpatient physicians – found that 67% reported high stress, 38% said they were “burned out,” 50% said they felt they had “low control” over their work, and 60% said they felt high documentation pressures. Still, 68% said they were satisfied with the values of their departments.

Hospitalists surveyed were actually less likely to say they were burned out, compared with outpatient internists – 52%, compared with 55% – but they were more likely to score low on a scale measuring personal accomplishments, compared with the outpatient clinicians – 20% to 10%. The survey found no significant difference between the two groups in depression or suicidality. But with 40% reporting depression and 10% reporting thoughts of suicide, the numbers virtually cry out for solutions.

Hospitalists in the HM19 workshop, as in other sessions at the Annual Conference, questioned whether the standard 7-days-on, 7-days-off work schedule – seven 12-hour shifts followed by 7 days off – allows hospitalists to pair their works lives with their personal lives in a sustainable way. They described the way that the stress and fatigue of such an intense work period bleeds into the days off that follow after it.

“By the end of seven 12’s, they’re bleary eyed, they’re upset, they go home (for) 2 days of washout before they even start to enjoy whatever life they have left,” said Jonathan Martin, MD, director of medicine at Cumberland Medical Center in Crossville, Tenn. “It’s hard to get hospitalists to buy in, which increases their dissatisfaction.”

Dr. Michtalik had a similar perspective.

“You just shut the rest of your life down completely for those 7 days and then, on your 7 days off, you’ve scheduled your life,” he said. “But that last off day – day number 7 – you feel that pit in your stomach, that the streak is coming.” He joked that the feeling was similar to the dread inspired by the phrase “winter is coming” in the popular HBO series “Game of Thrones.”

Systematic reviews of the literature have found that it’s mostly changes at the organization level – rather than changes that an individual physician makes on his or her own – that tend to make significant differences. Changes to structure, communication, and scheduling tend to work better than working on mindfulness, education, or trying to improve resilience, Dr. Michtalik said.

In one study discussed at the HM19 workshop, researchers compared a schedule in which an intensivist works in-house for 7 days, with home call at night, to a schedule in which the intensivist is completely off at night, with an in-house intensivist covering the night shift. The schedule in which the intensivist was truly off for the night significantly reduced reports of burnout, while not affecting length of stay or patient-experience outcomes.

Dr. Michtalik said that another study compared 4-week rotations to 2-week rotations for attending physicians. Researchers found that the 2-week version resulted in lower reports of burnout, with readmissions and patient experience unaffected, although they noted that residents tended to prefer 4-week schedules because they felt it resulted in better relationships with the attending physician.

Perhaps the dominant factor in job satisfaction that’s been identified in surveys is how physicians, patients, and administrators relate to one another, Dr. Michtalik said.

“The important concept here is that relationships were really important in driving job satisfaction, whether that be with our colleagues, our patients, or with the staff that you’re working with,” he said. “It’s always easier to decline a consultation or have a bad interaction with someone over the phone than it is if you actually know them or you are communicating face to face. That’s why it’s important to develop these kinds of relationships, which also put a face to what’s going on.”
 

Beyond salary adjustments

Hospitalists attending the HM19 workshop said they thought that participating in administration committees at their own institutions helps keep hospitalists involved in hospital matters, limiting the effects of burnout and improving workplace satisfaction.

Kevin McAninch, DO, a hospitalist with Central Ohio Primary Care in Westerville, said a shift in work responsibilities has made an improvement at his hospital. There is now an “inpatient support center” – which has a physician and a nurse in an office taking calls from 6 p.m. to 7 a.m., so that rounders can stop taking floor calls during that time.

The system “takes the pressure off our admitters at night and our nurses because they’re not getting floor calls anymore, so they’re just taking care of the admissions from the ER,” he said.

A recurring theme of the discussion was that salary alone seems universally incapable of eradicating feelings of burnout. One hospitalist said that in surveys, higher-paid physicians insist that monetary compensation is their main driver, but still often complain of burnout because they must work extra shifts to earn that higher level of pay.

Instead, burnout and satisfaction indicators tend to have more do to with time, control, and support, Dr. Michtalik noted.

Mangla Gulati, MD, SFHM, chief quality officer at the University of Maryland Medical Center in Baltimore, said that there’s no big secret about what hospitalists want from their places of employment. They want things like getting patients to service faster so they can make diagnoses, making sure patients get the care they need, fixing the problems associated with electronic medical records, and having a work-life “integration.”

“The questions is – how do we get there?” Dr. Gulati wondered. She suggested that hospitalists have to be more assertive and explanatory in their interactions with members of the hospital C-suite.

“I think it’s really important for you to understand or ask your C-suite, ‘Where are you in this whole journey? What is your perception of wellness? Tell me some of the measures of staff wellness,’ ” she said.

If the C-suite says “we have no money” to make improvements, hospitalists must be willing to say, ‘Well, you’re going to have to invest a little bit.’ ” Dr. Gulati said. “What is the ROI (return on investment) on the turnover of a physician? Because when you turn a physician over, you have to recruit and hire new staff.”

Dr. Gulati said that hospitalists should provide C-suite leaders with a detailed walk-through of their actual workflows – what their workdays look like – because “it’s not something they’re familiar with.”

Aside from improving relations with hospital administration, Dr. Gulati suggested creating CME programs for wellness, offering time and funding for physician support meetings, supporting flexibility in work hours, and creating programs specifically to help clinicians with burnout symptoms.

She also touted the benefits of “Schwartz Rounds,” in which several medical disciplines gather to talk about a case that was particularly challenging, clinically complex, and emotionally draining for everyone involved.

At Cumberland Medical Center, Dr. Martin said he has two meetings a month with executives in the hospital’s C-suite. One is with his hospitalist group, TeamHealth, and one is more direct, between himself and hospital administrators. It’s just 2 hours a month, but these conversations have undoubtedly helped, he said, although he cautioned that “the meetings themselves don’t have as much meaning if you aren’t communicating effectively,” meaning hospitalists must understand how the C-suite thinks and learn to speak in terms they understand.

“When I go to the administration now and I say ‘Hey, this is a problem that we’re having. I need your help in solving it,’ the executives are much more likely to respond to me than if they’d never seen me, or only see me rarely,” Dr. Martin said.

As a result, a collaborative approach to such conversations tends to be more effective.

“If you go to the C-suite and say, ‘Here’s our issue, how can you help us?’ – as opposed to telling the administration, ‘This is what I need’ – they are more likely to work with you to generate a solution.”

ORLANDO – A genetic profile that’s considered risky for psychosis matters more for patients who come from an environmental background that is considered good, while it doesn’t seem to make much of a difference among those whose environmental background is more adverse, according to research presented at the annual congress of the Schizophrenia International Research Society.

Researchers at the University of Pennsylvania, Philadelphia, are examining a wide variety of data – from socioeconomic factors to neuroimaging – to assess how these data all feed into the psychosis picture, asking whether some factors matter more than others and which factors can be used to predict the development of psychosis in the future.

“The goal of all of the research ... is to try and capture people earlier in the course of development where we can try and tweak the developmental trajectory,” said Raquel Gur, MD, PhD, professor of psychiatry, neurology, and radiology at the university.

The findings come from the Philadelphia Neurodevelopmental Cohort, a community sample of about 9,500 children and young adults aged 8-21 years, with an average age of 15 years, collected through pediatricians. About 1,600 had neuroimaging. Researchers followed 961 participants who had baseline measurements recorded and were seen at follow-up visits after 2 years and 4 years, or longer.

Participants had clinical testing done to determine traumatic stressful events and to look for symptoms seen as precursors to psychosis. They also had neurocognitive battery tests performed. Neuroimaging, genomics testing, and information from their electronic medical record were also examined.

One of the most salient findings so far in their ongoing analysis involved the relationship between polygenic risk score (PRS) and their environmental risk score (ERS), which factored in items such as household income from their geographic area, percentage of married adults in their area, crime rates in their area, and traumatic stressful events experienced personally. The ERS scores were grouped into “good” scores and “bad” scores.

Researchers saw a trend in which, among those with good ERS scores, the average PRS was higher for those with psychotic spectrum symptoms than for those with normal development, with very little overlapping of 95% confidence intervals. But among those with bad ERS scores, the average PRS was about the same for those with psychotic spectrum symptoms and those with normal development.

“If you have genetic vulnerability, a good environment is not going to protect you. You’re going to manifest it,” Dr. Gur said. “However, in a negative environment that has adversity that includes both a poor environment and traumatic events, the polygenic risk score matters less.”

Researchers also saw differences in volume in key areas of the brain, before symptoms arose, among those who eventually developed psychosis symptoms, Dr. Gur said. They are continuing to explore and assess these findings.

The researchers also found differences in cognitive functioning among those with poor environmental scores, which dovetail with defects seen in schizophrenia, such as executive functioning.

“Neurocognitive functioning can be established with brief computerized testing,” Dr. Gur said, “and shows deficit in the psychosis spectrum group in domains that have been implicated in schizophrenia.”

Dr. Gur reported no relevant financial disclosures.

ORLANDO – A genetic profile that’s considered risky for psychosis matters more for patients who come from an environmental background that is considered good, while it doesn’t seem to make much of a difference among those whose environmental background is more adverse, according to research presented at the annual congress of the Schizophrenia International Research Society.

Researchers at the University of Pennsylvania, Philadelphia, are examining a wide variety of data – from socioeconomic factors to neuroimaging – to assess how these data all feed into the psychosis picture, asking whether some factors matter more than others and which factors can be used to predict the development of psychosis in the future.

“The goal of all of the research ... is to try and capture people earlier in the course of development where we can try and tweak the developmental trajectory,” said Raquel Gur, MD, PhD, professor of psychiatry, neurology, and radiology at the university.

The findings come from the Philadelphia Neurodevelopmental Cohort, a community sample of about 9,500 children and young adults aged 8-21 years, with an average age of 15 years, collected through pediatricians. About 1,600 had neuroimaging. Researchers followed 961 participants who had baseline measurements recorded and were seen at follow-up visits after 2 years and 4 years, or longer.

Participants had clinical testing done to determine traumatic stressful events and to look for symptoms seen as precursors to psychosis. They also had neurocognitive battery tests performed. Neuroimaging, genomics testing, and information from their electronic medical record were also examined.

One of the most salient findings so far in their ongoing analysis involved the relationship between polygenic risk score (PRS) and their environmental risk score (ERS), which factored in items such as household income from their geographic area, percentage of married adults in their area, crime rates in their area, and traumatic stressful events experienced personally. The ERS scores were grouped into “good” scores and “bad” scores.

Researchers saw a trend in which, among those with good ERS scores, the average PRS was higher for those with psychotic spectrum symptoms than for those with normal development, with very little overlapping of 95% confidence intervals. But among those with bad ERS scores, the average PRS was about the same for those with psychotic spectrum symptoms and those with normal development.

“If you have genetic vulnerability, a good environment is not going to protect you. You’re going to manifest it,” Dr. Gur said. “However, in a negative environment that has adversity that includes both a poor environment and traumatic events, the polygenic risk score matters less.”

Researchers also saw differences in volume in key areas of the brain, before symptoms arose, among those who eventually developed psychosis symptoms, Dr. Gur said. They are continuing to explore and assess these findings.

The researchers also found differences in cognitive functioning among those with poor environmental scores, which dovetail with defects seen in schizophrenia, such as executive functioning.

“Neurocognitive functioning can be established with brief computerized testing,” Dr. Gur said, “and shows deficit in the psychosis spectrum group in domains that have been implicated in schizophrenia.”

Dr. Gur reported no relevant financial disclosures.

ORLANDO – A genetic profile that’s considered risky for psychosis matters more for patients who come from an environmental background that is considered good, while it doesn’t seem to make much of a difference among those whose environmental background is more adverse, according to research presented at the annual congress of the Schizophrenia International Research Society.

Researchers at the University of Pennsylvania, Philadelphia, are examining a wide variety of data – from socioeconomic factors to neuroimaging – to assess how these data all feed into the psychosis picture, asking whether some factors matter more than others and which factors can be used to predict the development of psychosis in the future.

“The goal of all of the research ... is to try and capture people earlier in the course of development where we can try and tweak the developmental trajectory,” said Raquel Gur, MD, PhD, professor of psychiatry, neurology, and radiology at the university.

The findings come from the Philadelphia Neurodevelopmental Cohort, a community sample of about 9,500 children and young adults aged 8-21 years, with an average age of 15 years, collected through pediatricians. About 1,600 had neuroimaging. Researchers followed 961 participants who had baseline measurements recorded and were seen at follow-up visits after 2 years and 4 years, or longer.

Participants had clinical testing done to determine traumatic stressful events and to look for symptoms seen as precursors to psychosis. They also had neurocognitive battery tests performed. Neuroimaging, genomics testing, and information from their electronic medical record were also examined.

One of the most salient findings so far in their ongoing analysis involved the relationship between polygenic risk score (PRS) and their environmental risk score (ERS), which factored in items such as household income from their geographic area, percentage of married adults in their area, crime rates in their area, and traumatic stressful events experienced personally. The ERS scores were grouped into “good” scores and “bad” scores.

Researchers saw a trend in which, among those with good ERS scores, the average PRS was higher for those with psychotic spectrum symptoms than for those with normal development, with very little overlapping of 95% confidence intervals. But among those with bad ERS scores, the average PRS was about the same for those with psychotic spectrum symptoms and those with normal development.

“If you have genetic vulnerability, a good environment is not going to protect you. You’re going to manifest it,” Dr. Gur said. “However, in a negative environment that has adversity that includes both a poor environment and traumatic events, the polygenic risk score matters less.”

Researchers also saw differences in volume in key areas of the brain, before symptoms arose, among those who eventually developed psychosis symptoms, Dr. Gur said. They are continuing to explore and assess these findings.

The researchers also found differences in cognitive functioning among those with poor environmental scores, which dovetail with defects seen in schizophrenia, such as executive functioning.

“Neurocognitive functioning can be established with brief computerized testing,” Dr. Gur said, “and shows deficit in the psychosis spectrum group in domains that have been implicated in schizophrenia.”

Dr. Gur reported no relevant financial disclosures.

ORLANDO – Infections before the age of 4 are linked to the risk of nonaffective psychosis (NAP) in adulthood, according to a study presented at the annual congress of the Schizophrenia International Research Society. Researchers also found that a lower IQ seems to make the psychosis risk more likely.

It’s well-established in the literature that infections are tied to schizophrenia and that a premorbid IQ deficit is linked as well. Researchers looked to a huge data pool from the Swedish population to try to better define these risks.

“We know that there is an association between infection and schizophrenia,” said Golam Khandaker, MRCPsych, PhD, head of the inflammation and psychiatry research group at the University of Cambridge (England). “We know that there is premorbid IQ deficit in schizophrenia. So, we wanted to know, is there a sensitive period during childhood when exposure to infection is more harmful?”

Researchers analyzed data for 647,000 people in the Swedish population who were born between 1973 and 1997, and conscripted for military service through 2010. Exposure to infection was considered to be any hospitalization with any serious infection between birth and age 13. IQ measurements were taken during military conscription at the age of 18. And researchers looked for risk of nonaffective psychosis from the age of 18 on.

There was a significant increase in risk of nonaffective psychosis in adulthood among those who’d had an infection, with a hazard ratio of 1.16 (95% confidence interval, 1.08-1.24). But when researchers broke down this risk into smaller age spans, they found that only infection between birth and 1 year old (HR, 1.19; 95% CI, 1.06-1.33) and between age 2 and 4 (HR, 1.11; 95% CI, 1.02-1.22) was linked with a significantly elevated risk of NAP. Researchers also saw a link between infection and IQ.

“It seems that early childhood is a sensitive period with regards to the effects of infection on IQ and risk of psychosis in adult life,” Dr. Khandaker said.

Researchers assessed whether familial factors could be confounding this link. They looked at rates of NAP among those with an early infection and no early infection in the general population and found that it was no different statistically than among full siblings with an early infection, compared with those with no early infection. In other words, the infection-psychosis risk was the same – whether someone was a close family member or not.

Dr. Khandaker said the findings more definitively establish a link between infection and psychosis risk and suggest that the early years are when children are at their most vulnerable.

“The association between adult nonaffective psychosis with premorbid IQ and childhood infection are not explained by shared familial confounding,” he said. “So these associations could be causal.”

When they looked at the role of IQ and the link between infection and psychosis risk, researchers found an interaction: With every 1-point decrease in IQ score, there was a corresponding increased risk of NAP among those with childhood infections (odds ratio, 1.006; P = .02).

“Childhood infections,” Dr. Khandaker said, “increase psychosis risk partly by interfering with neurodevelopment, and partly by exaggerating the effects of cognitive vulnerability to psychosis.”

Dr. Khandaker disclosed no relevant financial relationships.

ORLANDO – Infections before the age of 4 are linked to the risk of nonaffective psychosis (NAP) in adulthood, according to a study presented at the annual congress of the Schizophrenia International Research Society. Researchers also found that a lower IQ seems to make the psychosis risk more likely.

It’s well-established in the literature that infections are tied to schizophrenia and that a premorbid IQ deficit is linked as well. Researchers looked to a huge data pool from the Swedish population to try to better define these risks.

“We know that there is an association between infection and schizophrenia,” said Golam Khandaker, MRCPsych, PhD, head of the inflammation and psychiatry research group at the University of Cambridge (England). “We know that there is premorbid IQ deficit in schizophrenia. So, we wanted to know, is there a sensitive period during childhood when exposure to infection is more harmful?”

Researchers analyzed data for 647,000 people in the Swedish population who were born between 1973 and 1997, and conscripted for military service through 2010. Exposure to infection was considered to be any hospitalization with any serious infection between birth and age 13. IQ measurements were taken during military conscription at the age of 18. And researchers looked for risk of nonaffective psychosis from the age of 18 on.

There was a significant increase in risk of nonaffective psychosis in adulthood among those who’d had an infection, with a hazard ratio of 1.16 (95% confidence interval, 1.08-1.24). But when researchers broke down this risk into smaller age spans, they found that only infection between birth and 1 year old (HR, 1.19; 95% CI, 1.06-1.33) and between age 2 and 4 (HR, 1.11; 95% CI, 1.02-1.22) was linked with a significantly elevated risk of NAP. Researchers also saw a link between infection and IQ.

“It seems that early childhood is a sensitive period with regards to the effects of infection on IQ and risk of psychosis in adult life,” Dr. Khandaker said.

Researchers assessed whether familial factors could be confounding this link. They looked at rates of NAP among those with an early infection and no early infection in the general population and found that it was no different statistically than among full siblings with an early infection, compared with those with no early infection. In other words, the infection-psychosis risk was the same – whether someone was a close family member or not.

Dr. Khandaker said the findings more definitively establish a link between infection and psychosis risk and suggest that the early years are when children are at their most vulnerable.

“The association between adult nonaffective psychosis with premorbid IQ and childhood infection are not explained by shared familial confounding,” he said. “So these associations could be causal.”

When they looked at the role of IQ and the link between infection and psychosis risk, researchers found an interaction: With every 1-point decrease in IQ score, there was a corresponding increased risk of NAP among those with childhood infections (odds ratio, 1.006; P = .02).

“Childhood infections,” Dr. Khandaker said, “increase psychosis risk partly by interfering with neurodevelopment, and partly by exaggerating the effects of cognitive vulnerability to psychosis.”

Dr. Khandaker disclosed no relevant financial relationships.

ORLANDO – Infections before the age of 4 are linked to the risk of nonaffective psychosis (NAP) in adulthood, according to a study presented at the annual congress of the Schizophrenia International Research Society. Researchers also found that a lower IQ seems to make the psychosis risk more likely.

It’s well-established in the literature that infections are tied to schizophrenia and that a premorbid IQ deficit is linked as well. Researchers looked to a huge data pool from the Swedish population to try to better define these risks.

“We know that there is an association between infection and schizophrenia,” said Golam Khandaker, MRCPsych, PhD, head of the inflammation and psychiatry research group at the University of Cambridge (England). “We know that there is premorbid IQ deficit in schizophrenia. So, we wanted to know, is there a sensitive period during childhood when exposure to infection is more harmful?”

Researchers analyzed data for 647,000 people in the Swedish population who were born between 1973 and 1997, and conscripted for military service through 2010. Exposure to infection was considered to be any hospitalization with any serious infection between birth and age 13. IQ measurements were taken during military conscription at the age of 18. And researchers looked for risk of nonaffective psychosis from the age of 18 on.

There was a significant increase in risk of nonaffective psychosis in adulthood among those who’d had an infection, with a hazard ratio of 1.16 (95% confidence interval, 1.08-1.24). But when researchers broke down this risk into smaller age spans, they found that only infection between birth and 1 year old (HR, 1.19; 95% CI, 1.06-1.33) and between age 2 and 4 (HR, 1.11; 95% CI, 1.02-1.22) was linked with a significantly elevated risk of NAP. Researchers also saw a link between infection and IQ.

“It seems that early childhood is a sensitive period with regards to the effects of infection on IQ and risk of psychosis in adult life,” Dr. Khandaker said.

Researchers assessed whether familial factors could be confounding this link. They looked at rates of NAP among those with an early infection and no early infection in the general population and found that it was no different statistically than among full siblings with an early infection, compared with those with no early infection. In other words, the infection-psychosis risk was the same – whether someone was a close family member or not.

Dr. Khandaker said the findings more definitively establish a link between infection and psychosis risk and suggest that the early years are when children are at their most vulnerable.

“The association between adult nonaffective psychosis with premorbid IQ and childhood infection are not explained by shared familial confounding,” he said. “So these associations could be causal.”

When they looked at the role of IQ and the link between infection and psychosis risk, researchers found an interaction: With every 1-point decrease in IQ score, there was a corresponding increased risk of NAP among those with childhood infections (odds ratio, 1.006; P = .02).

“Childhood infections,” Dr. Khandaker said, “increase psychosis risk partly by interfering with neurodevelopment, and partly by exaggerating the effects of cognitive vulnerability to psychosis.”

Dr. Khandaker disclosed no relevant financial relationships.