Mixed Topics

Although readers will be forgiven for missing the subtle change, the tables in the 2020 State of Hospital Medicine (SoHM) Report underwent a landmark structural change that echoes the growth of our field. In the latest SoHM Report, the hospital medicine group (HMG) size categories all increased significantly to reflect the fact that hospitalist groups have grown from a median of 9 physician full time equivalents (FTE) in 2016 to a median of 15.2 employed/contracted FTE (excluding FTE provided by locum tenens providers) in 2020.

For many years, the Report considered “large” adult HMGs to be those with 30 or more FTE of physicians, and smaller groups were organized by FTE categories of <5, 5-9, 10-19, and 20-29. Now the SoHM Report describes a large HMG as 50 employed/contracted FTE or greater, a category that represents 12.7% of HMGs serving adults. The other categories expanded to <5, 5-14, 15-29, and 30-49, respectively. Overall, HMGs are growing in size, and the SoHM displays new data slices that help leaders to compare their group to modern peers.

There are some caveats to consider. First, these figures only represent physician FTE, and essentially all these large groups employ NP/PA hospitalists as well. Second, these HMGs typically employ some part-time and contracted PRN physicians in this FTE count. In combination, these two factors mean that large HMGs often employ many more than 50 individual clinicians. In fact, the average number of physicians in this cohort was 72.3 before counting NP/PAs and locums. Third, do not interpret the portion of large groups in the survey (12.7%) as insignificant. Because each one employs so many total hospitalists, large HMGs collectively represent a common work environment for many hospitalists in the US. Lastly, although pediatric HMGs have grown, far fewer (3.1%) have over 50 FTE, so this column focuses on HMGs serving adults.

Why does it matter that groups are growing in size? The SoHM Report offers extensive data to answer this question. Here are a couple of highlights but consider buying the report to dig deeper. First, large groups are far more likely to offer variable scheduling. Although the 7-on, 7-off scheduling pattern is still the norm in all group sizes, large HMGs are most likely to offer something flexible that might enhance career sustainability for hospitalists. Second, large groups are the most likely to employ a few hospitalists with extra training, whether that be geriatrics, palliative care, pediatrics, or a medicine subspecialty. Working in a large group means you can ask for curbside consults from a diverse and well-trained bunch of colleagues. Third, large groups were most likely to employ nocturnists, meaning fewer night shifts are allocated to the hospitalists who want to focus on daytime work. From an individual perspective, there is a lot to like about working in a large HMG.

There are some drawbacks to larger groups, of course. Large groups can be less socially cohesive and the costs of managing 70-100 hospitalists typically grow well past the capacity of a single group leader. My personal belief is that these downsides can be solved through economies of scale and skilled management teams. In addition, a large group can afford to dedicate leadership FTE to niche hospitalist needs, such as career development and coaching, which are difficult to fund in small practices. This also provides more opportunities for staff hospitalists to begin taking on some leadership or administrative duties or branch out into related areas such as quality improvement, case management physician advisor roles, or IT expertise.

Ultimately, large groups typically represent the maturation of an HMG within a large hospital – it signifies that the hospital relies on that group to deliver great patient outcomes in every corner of the hospital. Where you practice remains a personal choice, but the emergence of large groups hints at the clout and sophistication hospitalists can build by banding together. Learn more about the full 2020 SoHM Report at hospitalmedicine.org/sohm.
 

Dr. White is associate professor of medicine at the University of Washington, Seattle. He is the chair of SHM’s Practice Analysis Committee.

Although readers will be forgiven for missing the subtle change, the tables in the 2020 State of Hospital Medicine (SoHM) Report underwent a landmark structural change that echoes the growth of our field. In the latest SoHM Report, the hospital medicine group (HMG) size categories all increased significantly to reflect the fact that hospitalist groups have grown from a median of 9 physician full time equivalents (FTE) in 2016 to a median of 15.2 employed/contracted FTE (excluding FTE provided by locum tenens providers) in 2020.

For many years, the Report considered “large” adult HMGs to be those with 30 or more FTE of physicians, and smaller groups were organized by FTE categories of <5, 5-9, 10-19, and 20-29. Now the SoHM Report describes a large HMG as 50 employed/contracted FTE or greater, a category that represents 12.7% of HMGs serving adults. The other categories expanded to <5, 5-14, 15-29, and 30-49, respectively. Overall, HMGs are growing in size, and the SoHM displays new data slices that help leaders to compare their group to modern peers.

There are some caveats to consider. First, these figures only represent physician FTE, and essentially all these large groups employ NP/PA hospitalists as well. Second, these HMGs typically employ some part-time and contracted PRN physicians in this FTE count. In combination, these two factors mean that large HMGs often employ many more than 50 individual clinicians. In fact, the average number of physicians in this cohort was 72.3 before counting NP/PAs and locums. Third, do not interpret the portion of large groups in the survey (12.7%) as insignificant. Because each one employs so many total hospitalists, large HMGs collectively represent a common work environment for many hospitalists in the US. Lastly, although pediatric HMGs have grown, far fewer (3.1%) have over 50 FTE, so this column focuses on HMGs serving adults.

Why does it matter that groups are growing in size? The SoHM Report offers extensive data to answer this question. Here are a couple of highlights but consider buying the report to dig deeper. First, large groups are far more likely to offer variable scheduling. Although the 7-on, 7-off scheduling pattern is still the norm in all group sizes, large HMGs are most likely to offer something flexible that might enhance career sustainability for hospitalists. Second, large groups are the most likely to employ a few hospitalists with extra training, whether that be geriatrics, palliative care, pediatrics, or a medicine subspecialty. Working in a large group means you can ask for curbside consults from a diverse and well-trained bunch of colleagues. Third, large groups were most likely to employ nocturnists, meaning fewer night shifts are allocated to the hospitalists who want to focus on daytime work. From an individual perspective, there is a lot to like about working in a large HMG.

There are some drawbacks to larger groups, of course. Large groups can be less socially cohesive and the costs of managing 70-100 hospitalists typically grow well past the capacity of a single group leader. My personal belief is that these downsides can be solved through economies of scale and skilled management teams. In addition, a large group can afford to dedicate leadership FTE to niche hospitalist needs, such as career development and coaching, which are difficult to fund in small practices. This also provides more opportunities for staff hospitalists to begin taking on some leadership or administrative duties or branch out into related areas such as quality improvement, case management physician advisor roles, or IT expertise.

Ultimately, large groups typically represent the maturation of an HMG within a large hospital – it signifies that the hospital relies on that group to deliver great patient outcomes in every corner of the hospital. Where you practice remains a personal choice, but the emergence of large groups hints at the clout and sophistication hospitalists can build by banding together. Learn more about the full 2020 SoHM Report at hospitalmedicine.org/sohm.
 

Dr. White is associate professor of medicine at the University of Washington, Seattle. He is the chair of SHM’s Practice Analysis Committee.

Although readers will be forgiven for missing the subtle change, the tables in the 2020 State of Hospital Medicine (SoHM) Report underwent a landmark structural change that echoes the growth of our field. In the latest SoHM Report, the hospital medicine group (HMG) size categories all increased significantly to reflect the fact that hospitalist groups have grown from a median of 9 physician full time equivalents (FTE) in 2016 to a median of 15.2 employed/contracted FTE (excluding FTE provided by locum tenens providers) in 2020.

For many years, the Report considered “large” adult HMGs to be those with 30 or more FTE of physicians, and smaller groups were organized by FTE categories of <5, 5-9, 10-19, and 20-29. Now the SoHM Report describes a large HMG as 50 employed/contracted FTE or greater, a category that represents 12.7% of HMGs serving adults. The other categories expanded to <5, 5-14, 15-29, and 30-49, respectively. Overall, HMGs are growing in size, and the SoHM displays new data slices that help leaders to compare their group to modern peers.

There are some caveats to consider. First, these figures only represent physician FTE, and essentially all these large groups employ NP/PA hospitalists as well. Second, these HMGs typically employ some part-time and contracted PRN physicians in this FTE count. In combination, these two factors mean that large HMGs often employ many more than 50 individual clinicians. In fact, the average number of physicians in this cohort was 72.3 before counting NP/PAs and locums. Third, do not interpret the portion of large groups in the survey (12.7%) as insignificant. Because each one employs so many total hospitalists, large HMGs collectively represent a common work environment for many hospitalists in the US. Lastly, although pediatric HMGs have grown, far fewer (3.1%) have over 50 FTE, so this column focuses on HMGs serving adults.

Why does it matter that groups are growing in size? The SoHM Report offers extensive data to answer this question. Here are a couple of highlights but consider buying the report to dig deeper. First, large groups are far more likely to offer variable scheduling. Although the 7-on, 7-off scheduling pattern is still the norm in all group sizes, large HMGs are most likely to offer something flexible that might enhance career sustainability for hospitalists. Second, large groups are the most likely to employ a few hospitalists with extra training, whether that be geriatrics, palliative care, pediatrics, or a medicine subspecialty. Working in a large group means you can ask for curbside consults from a diverse and well-trained bunch of colleagues. Third, large groups were most likely to employ nocturnists, meaning fewer night shifts are allocated to the hospitalists who want to focus on daytime work. From an individual perspective, there is a lot to like about working in a large HMG.

There are some drawbacks to larger groups, of course. Large groups can be less socially cohesive and the costs of managing 70-100 hospitalists typically grow well past the capacity of a single group leader. My personal belief is that these downsides can be solved through economies of scale and skilled management teams. In addition, a large group can afford to dedicate leadership FTE to niche hospitalist needs, such as career development and coaching, which are difficult to fund in small practices. This also provides more opportunities for staff hospitalists to begin taking on some leadership or administrative duties or branch out into related areas such as quality improvement, case management physician advisor roles, or IT expertise.

Ultimately, large groups typically represent the maturation of an HMG within a large hospital – it signifies that the hospital relies on that group to deliver great patient outcomes in every corner of the hospital. Where you practice remains a personal choice, but the emergence of large groups hints at the clout and sophistication hospitalists can build by banding together. Learn more about the full 2020 SoHM Report at hospitalmedicine.org/sohm.
 

Dr. White is associate professor of medicine at the University of Washington, Seattle. He is the chair of SHM’s Practice Analysis Committee.

A 16-minute podcast from JAMA: The Journal of the American Medical Association that attempts to discuss structural racism in the U.S. health care system has stirred conversation on social media about the handling and promotion of the episode.

Published on Feb. 23, the episode is hosted on JAMA’s learning platform for doctors and is available for continuing medical education credits.

“No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast,” JAMA wrote in a Twitter post to promote the episode. That tweet has since been deleted.

“Systemic and interpersonal racism both still exist in our country — they must be rooted out. I do not share the JAMA host’s belief of doing away with the word ‘racism’ will help us be more successful in ending inequities that exists across racial and ethnic lines,” Dr. Katz said. “Further, I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity.”

Dr. Katz reiterated that both interpersonal and structural racism continue to exist in the United States, “and it is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it.”

He also recommended JAMA use this controversy “as a learning opportunity for continued dialogue and create another podcast series as an open conversation that invites diverse experts in the field to have an open discussion about structural racism in healthcare.”

The podcast and JAMA’s tweet promoting it were widely criticized on Twitter. In interviews with WebMD, many doctors expressed disbelief that such a respected journal would lend its name to this podcast episode.

B. Bobby Chiong, MD, a radiologist in New York, said although JAMA’s effort to engage with its audience about racism is laudable, it missed the mark.

“I think the backlash comes from how they tried to make a podcast about the subject and somehow made themselves an example of unconscious bias and unfamiliarity with just how embedded in our system is structural racism,” he said. 

Perhaps the podcast’s worst offense was its failure to address the painful history of racial bias in this country that still permeates the medical community, says Tamara Saint-Surin, MD, assistant professor at the University of North Carolina at Chapel Hill.

“For physicians in leadership to have the belief that structural racism does not exist in medicine, they don’t really appreciate what affects their patients and what their patients were dealing with,” Dr. Saint-Surin said in an interview. “It was a very harmful podcast and goes to show we still have so much work to do.”

Along with a flawed premise, she says, the podcast was not nearly long enough to address such a nuanced issue. And Dr. Livingston focused on interpersonal racism rather than structural racism, she said, failing to address widespread problems such as higher rates of asthma among Black populations living in areas with poor air quality.

The number of Black doctors remains low and the lack of representation adds to an environment already rife with racism, according to many medical professionals.

Shirlene Obuobi, MD, an internal medicine doctor in Chicago, said JAMA failed to live up to its own standards by publishing material that lacked research and expertise.

“I can’t submit a clinical trial to JAMA without them combing through methods with a fine-tooth comb,” Dr. Obuobi said. “They didn’t uphold the standards they normally apply to anyone else.”

Both the editor of JAMA and the head of the American Medical Association issued statements criticizing the episode and the tweet that promoted it.

JAMA Editor-in-Chief Howard Bauchner, MD, said, “The language of the tweet, and some portions of the podcast, do not reflect my commitment as editorial leader of JAMA and JAMA Network to call out and discuss the adverse effects of injustice, inequity, and racism in society and medicine as JAMA has done for many years.” He said JAMA will schedule a future podcast to address the concerns raised about the recent episode.

AMA CEO James L. Madara, MD, said, “The AMA’s House of Delegates passed policy stating that racism is structural, systemic, cultural, and interpersonal, and we are deeply disturbed – and angered – by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet that promoted the podcast and stated ‘no physician is racist, so how can there be structural racism in health care?’ ”

He continued: “JAMA has editorial independence from AMA, but this tweet and podcast are inconsistent with the policies and views of AMA, and I’m concerned about and acknowledge the harms they have caused. Structural racism in health care and our society exists, and it is incumbent on all of us to fix it.”

This article was updated 3/5/21.

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

A 16-minute podcast from JAMA: The Journal of the American Medical Association that attempts to discuss structural racism in the U.S. health care system has stirred conversation on social media about the handling and promotion of the episode.

Published on Feb. 23, the episode is hosted on JAMA’s learning platform for doctors and is available for continuing medical education credits.

“No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast,” JAMA wrote in a Twitter post to promote the episode. That tweet has since been deleted.

“Systemic and interpersonal racism both still exist in our country — they must be rooted out. I do not share the JAMA host’s belief of doing away with the word ‘racism’ will help us be more successful in ending inequities that exists across racial and ethnic lines,” Dr. Katz said. “Further, I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity.”

Dr. Katz reiterated that both interpersonal and structural racism continue to exist in the United States, “and it is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it.”

He also recommended JAMA use this controversy “as a learning opportunity for continued dialogue and create another podcast series as an open conversation that invites diverse experts in the field to have an open discussion about structural racism in healthcare.”

The podcast and JAMA’s tweet promoting it were widely criticized on Twitter. In interviews with WebMD, many doctors expressed disbelief that such a respected journal would lend its name to this podcast episode.

B. Bobby Chiong, MD, a radiologist in New York, said although JAMA’s effort to engage with its audience about racism is laudable, it missed the mark.

“I think the backlash comes from how they tried to make a podcast about the subject and somehow made themselves an example of unconscious bias and unfamiliarity with just how embedded in our system is structural racism,” he said. 

Perhaps the podcast’s worst offense was its failure to address the painful history of racial bias in this country that still permeates the medical community, says Tamara Saint-Surin, MD, assistant professor at the University of North Carolina at Chapel Hill.

“For physicians in leadership to have the belief that structural racism does not exist in medicine, they don’t really appreciate what affects their patients and what their patients were dealing with,” Dr. Saint-Surin said in an interview. “It was a very harmful podcast and goes to show we still have so much work to do.”

Along with a flawed premise, she says, the podcast was not nearly long enough to address such a nuanced issue. And Dr. Livingston focused on interpersonal racism rather than structural racism, she said, failing to address widespread problems such as higher rates of asthma among Black populations living in areas with poor air quality.

The number of Black doctors remains low and the lack of representation adds to an environment already rife with racism, according to many medical professionals.

Shirlene Obuobi, MD, an internal medicine doctor in Chicago, said JAMA failed to live up to its own standards by publishing material that lacked research and expertise.

“I can’t submit a clinical trial to JAMA without them combing through methods with a fine-tooth comb,” Dr. Obuobi said. “They didn’t uphold the standards they normally apply to anyone else.”

Both the editor of JAMA and the head of the American Medical Association issued statements criticizing the episode and the tweet that promoted it.

JAMA Editor-in-Chief Howard Bauchner, MD, said, “The language of the tweet, and some portions of the podcast, do not reflect my commitment as editorial leader of JAMA and JAMA Network to call out and discuss the adverse effects of injustice, inequity, and racism in society and medicine as JAMA has done for many years.” He said JAMA will schedule a future podcast to address the concerns raised about the recent episode.

AMA CEO James L. Madara, MD, said, “The AMA’s House of Delegates passed policy stating that racism is structural, systemic, cultural, and interpersonal, and we are deeply disturbed – and angered – by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet that promoted the podcast and stated ‘no physician is racist, so how can there be structural racism in health care?’ ”

He continued: “JAMA has editorial independence from AMA, but this tweet and podcast are inconsistent with the policies and views of AMA, and I’m concerned about and acknowledge the harms they have caused. Structural racism in health care and our society exists, and it is incumbent on all of us to fix it.”

This article was updated 3/5/21.

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

A 16-minute podcast from JAMA: The Journal of the American Medical Association that attempts to discuss structural racism in the U.S. health care system has stirred conversation on social media about the handling and promotion of the episode.

Published on Feb. 23, the episode is hosted on JAMA’s learning platform for doctors and is available for continuing medical education credits.

“No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast,” JAMA wrote in a Twitter post to promote the episode. That tweet has since been deleted.

“Systemic and interpersonal racism both still exist in our country — they must be rooted out. I do not share the JAMA host’s belief of doing away with the word ‘racism’ will help us be more successful in ending inequities that exists across racial and ethnic lines,” Dr. Katz said. “Further, I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity.”

Dr. Katz reiterated that both interpersonal and structural racism continue to exist in the United States, “and it is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it.”

He also recommended JAMA use this controversy “as a learning opportunity for continued dialogue and create another podcast series as an open conversation that invites diverse experts in the field to have an open discussion about structural racism in healthcare.”

The podcast and JAMA’s tweet promoting it were widely criticized on Twitter. In interviews with WebMD, many doctors expressed disbelief that such a respected journal would lend its name to this podcast episode.

B. Bobby Chiong, MD, a radiologist in New York, said although JAMA’s effort to engage with its audience about racism is laudable, it missed the mark.

“I think the backlash comes from how they tried to make a podcast about the subject and somehow made themselves an example of unconscious bias and unfamiliarity with just how embedded in our system is structural racism,” he said. 

Perhaps the podcast’s worst offense was its failure to address the painful history of racial bias in this country that still permeates the medical community, says Tamara Saint-Surin, MD, assistant professor at the University of North Carolina at Chapel Hill.

“For physicians in leadership to have the belief that structural racism does not exist in medicine, they don’t really appreciate what affects their patients and what their patients were dealing with,” Dr. Saint-Surin said in an interview. “It was a very harmful podcast and goes to show we still have so much work to do.”

Along with a flawed premise, she says, the podcast was not nearly long enough to address such a nuanced issue. And Dr. Livingston focused on interpersonal racism rather than structural racism, she said, failing to address widespread problems such as higher rates of asthma among Black populations living in areas with poor air quality.

The number of Black doctors remains low and the lack of representation adds to an environment already rife with racism, according to many medical professionals.

Shirlene Obuobi, MD, an internal medicine doctor in Chicago, said JAMA failed to live up to its own standards by publishing material that lacked research and expertise.

“I can’t submit a clinical trial to JAMA without them combing through methods with a fine-tooth comb,” Dr. Obuobi said. “They didn’t uphold the standards they normally apply to anyone else.”

Both the editor of JAMA and the head of the American Medical Association issued statements criticizing the episode and the tweet that promoted it.

JAMA Editor-in-Chief Howard Bauchner, MD, said, “The language of the tweet, and some portions of the podcast, do not reflect my commitment as editorial leader of JAMA and JAMA Network to call out and discuss the adverse effects of injustice, inequity, and racism in society and medicine as JAMA has done for many years.” He said JAMA will schedule a future podcast to address the concerns raised about the recent episode.

AMA CEO James L. Madara, MD, said, “The AMA’s House of Delegates passed policy stating that racism is structural, systemic, cultural, and interpersonal, and we are deeply disturbed – and angered – by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet that promoted the podcast and stated ‘no physician is racist, so how can there be structural racism in health care?’ ”

He continued: “JAMA has editorial independence from AMA, but this tweet and podcast are inconsistent with the policies and views of AMA, and I’m concerned about and acknowledge the harms they have caused. Structural racism in health care and our society exists, and it is incumbent on all of us to fix it.”

This article was updated 3/5/21.

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

One of the biggest conundrums of the COVID-19 pandemic has been the simultaneous panic-hiring of medical professionals in hot spots and significant downsizing of staff across the country. From huge hospital systems to private practices, the stoppage of breast reductions and knee replacements, not to mention the drops in motor vehicle accidents and bar fights, have quieted operating rooms and emergency departments and put doctors’ jobs on the chopping block. A widely cited survey suggests that 21% of doctors have had a work reduction due to COVID-19.

For many American doctors, this is their first extended period of unemployment. Unlike engineers or those with MBAs who might see their fortunes rise and fall with the whims of recessions and boom times, physicians are not exactly accustomed to being laid off. However, doctors were already smarting for years due to falling salaries and decreased autonomy, punctuated by endless clicks on electronic medical records software.

Now, the twin shock of income loss and feeling unwanted in a pandemic – when, you know, medicine might seem especially essential – has doctors resorting to a bizarre array of side gigs, “fun-employment” activities, or outright career overhauls.

Stephanie Eschenbach Morgan, MD, a breast radiologist in North Carolina, trained for 10 years after college before earning a true physician’s salary.

“Being furloughed was awful. Initially, it was only going to be 2 weeks, and then it turned into 2 months with no pay,” she reflected.

Dr. Eschenbach Morgan and her surgeon husband, who lost a full quarter’s salary, had to ask for grace periods on their credit card and mortgage payments because they had paid a large tax bill right before the pandemic began. “We couldn’t get any stimulus help, so that added insult to injury,” she said.

With her time spent waiting in a holding pattern, Dr. Eschenbach Morgan homeschooled her two young children and started putting a home gym together. She went on a home organizing spree, started a garden, and, perhaps most impressively, caught up with 5 years of photo albums.

A bonus she noted: “I didn’t set an alarm for 2 months.”

Shella Farooki, MD, a radiologist in California, was also focused on homeschooling, itself a demanding job, and veered toward retirement. When one of her work contracts furloughed her (“at one point, I made $30K a month for [their business]”), she started saving money at home, teaching the kids, and applied for a Paycheck Protection Program loan. Her husband, a hospitalist, had had his shifts cut. Dr. Farooki tried a radiology artificial intelligence firm but backed out when she was asked to read 9,200 studies for them for $2,000 per month.

Now, she thinks about leaving medicine “every day.”

Some doctors are questioning whether they should be in medicine in the first place. Family medicine physician Jonathan Polak, MD, faced with his own pink slip, turned to pink T-shirts instead. His girlfriend manages an outlet of the teen fashion retailer Justice. Dr. Polak, who finished his residency just 2 years ago, didn’t hesitate to take a $10-an-hour gig as a stock doc, once even finding himself delivering a shelving unit from the shuttering store to a physician fleeing the city for rural New Hampshire to “escape.”

There’s no escape for him – yet. Saddled with “astronomical” student loans, he had considered grocery store work as well. Dr. Polak knows he can’t work part time or go into teaching long term, as he might like.

Even so, he’s doing everything he can to not be in patient care for the long haul – it’s just not what he thought it would be.

“The culture of medicine, bureaucracy, endless paperwork and charting, and threat of litigation sucks a lot of the joy out of it to the point that I don’t see myself doing it forever when imagining myself 5-10 years into it.”

Still, he recently took an 18-month hospital contract that will force him to move to Florida, but he’s also been turning himself into a veritable Renaissance man; composing music, training for an ultramarathon, studying the latest medical findings, roadtripping, and launching a podcast about dog grooming with a master groomer. “We found parallels between medicine and dog grooming,” he says, somewhat convincingly.

Also working the ruff life is Jen Tserng, MD, a former forensic pathologist who landed on news websites in recent years for becoming a professional dogwalker and housesitter without a permanent home. Dr. Tserng knows doctors were restless and unhappy before COVID-19, their thoughts wandering where the grass might be greener.

As her profile grew, she found her inbox gathering messages from disaffected medical minions: students with a fear of failing or staring down residency application season and employed doctors sick of the constant grind. As she recounted those de facto life coach conversations (“What do you really enjoy?” “Do you really like dogs?”) by phone from New York, she said matter-of-factly, “They don’t call because of COVID. They call because they hate their lives.”

Michelle Mudge-Riley, MD, a physician in Texas, has been seeing this shift for some time as well. She recently held a virtual version of her Physicians Helping Physicians conference, where doctors hear from their peers working successfully in fields like pharmaceuticals and real estate investing.

When COVID-19 hit, Dr. Mudge-Riley quickly pivoted to a virtual platform, where the MDs and DOs huddled in breakout rooms having honest chats about their fears and tentative hopes about their new careers.

“There has been increased interest in nonclinical exploration into full- and part-time careers, as well as side hustles, since COVID began,” she said. “Many physicians have had their hours or pay cut, and some have been laid off. Others are furloughed. Some just want out of an environment where they don’t feel safe.”

An ear, nose, and throat surgeon, Maansi Doshi, MD, from central California, didn’t feel safe – so she left. She had returned from India sick with a mystery virus right as the pandemic began (she said her COVID-19 tests were all negative) and was waiting to get well enough to go back to her private practice job. However, she said she clashed with Trump-supporting colleagues she feared might not be taking the pandemic seriously enough.

Finally getting over a relapse of her mystery virus, Dr. Doshi emailed her resignation in May. Her husband, family practice doctor Mark Mangiapane, MD, gave his job notice weeks later in solidarity because he worked in the same building. Together, they have embraced gardening, a Peloton splurge, and learning business skills to open private practices – solo primary care for him; ENT with a focus on her favorite surgery, rhinoplasty, for her.

Dr. Mangiapane had considered editing medical brochures and also tried to apply for a job as a county public health officer in rural California, but he received his own shock when he learned the county intended to open schools in the midst of the pandemic despite advisement to the contrary by the former health officer.

He retreated from job listings altogether after hearing his would-be peers were getting death threats – targeting their children.

Both doctors felt COVID-19 pushed them beyond their comfort zones. “If COVID hadn’t happened, I would be working. ... Be ‘owned.’ In a weird way, COVID made me more independent and take a risk with my career.”

Obstetrician Kwandaa Roberts, MD, certainly did; she took a budding interest in decorating dollhouses straight to Instagram and national news fame, and she is now a TV-show expert on “Sell This House.”

Like Dr. Doshi and Dr. Mangiapane, Dr. Polak wants to be more in control of his future – even if selling T-shirts at a mall means a certain loss of status along the way.

“Aside from my passion to learn and to have that connection with people, I went into medicine ... because of the job security I thought existed,” he said. “I would say that my getting furloughed has changed my view of the United States in a dramatic way. I do not feel as confident in the U.S. economy and general way of life as I did a year ago. And I am taking a number of steps to put myself in a more fluid, adaptable position in case another crisis like this occurs or if the current state of things worsens.”

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

One of the biggest conundrums of the COVID-19 pandemic has been the simultaneous panic-hiring of medical professionals in hot spots and significant downsizing of staff across the country. From huge hospital systems to private practices, the stoppage of breast reductions and knee replacements, not to mention the drops in motor vehicle accidents and bar fights, have quieted operating rooms and emergency departments and put doctors’ jobs on the chopping block. A widely cited survey suggests that 21% of doctors have had a work reduction due to COVID-19.

For many American doctors, this is their first extended period of unemployment. Unlike engineers or those with MBAs who might see their fortunes rise and fall with the whims of recessions and boom times, physicians are not exactly accustomed to being laid off. However, doctors were already smarting for years due to falling salaries and decreased autonomy, punctuated by endless clicks on electronic medical records software.

Now, the twin shock of income loss and feeling unwanted in a pandemic – when, you know, medicine might seem especially essential – has doctors resorting to a bizarre array of side gigs, “fun-employment” activities, or outright career overhauls.

Stephanie Eschenbach Morgan, MD, a breast radiologist in North Carolina, trained for 10 years after college before earning a true physician’s salary.

“Being furloughed was awful. Initially, it was only going to be 2 weeks, and then it turned into 2 months with no pay,” she reflected.

Dr. Eschenbach Morgan and her surgeon husband, who lost a full quarter’s salary, had to ask for grace periods on their credit card and mortgage payments because they had paid a large tax bill right before the pandemic began. “We couldn’t get any stimulus help, so that added insult to injury,” she said.

With her time spent waiting in a holding pattern, Dr. Eschenbach Morgan homeschooled her two young children and started putting a home gym together. She went on a home organizing spree, started a garden, and, perhaps most impressively, caught up with 5 years of photo albums.

A bonus she noted: “I didn’t set an alarm for 2 months.”

Shella Farooki, MD, a radiologist in California, was also focused on homeschooling, itself a demanding job, and veered toward retirement. When one of her work contracts furloughed her (“at one point, I made $30K a month for [their business]”), she started saving money at home, teaching the kids, and applied for a Paycheck Protection Program loan. Her husband, a hospitalist, had had his shifts cut. Dr. Farooki tried a radiology artificial intelligence firm but backed out when she was asked to read 9,200 studies for them for $2,000 per month.

Now, she thinks about leaving medicine “every day.”

Some doctors are questioning whether they should be in medicine in the first place. Family medicine physician Jonathan Polak, MD, faced with his own pink slip, turned to pink T-shirts instead. His girlfriend manages an outlet of the teen fashion retailer Justice. Dr. Polak, who finished his residency just 2 years ago, didn’t hesitate to take a $10-an-hour gig as a stock doc, once even finding himself delivering a shelving unit from the shuttering store to a physician fleeing the city for rural New Hampshire to “escape.”

There’s no escape for him – yet. Saddled with “astronomical” student loans, he had considered grocery store work as well. Dr. Polak knows he can’t work part time or go into teaching long term, as he might like.

Even so, he’s doing everything he can to not be in patient care for the long haul – it’s just not what he thought it would be.

“The culture of medicine, bureaucracy, endless paperwork and charting, and threat of litigation sucks a lot of the joy out of it to the point that I don’t see myself doing it forever when imagining myself 5-10 years into it.”

Still, he recently took an 18-month hospital contract that will force him to move to Florida, but he’s also been turning himself into a veritable Renaissance man; composing music, training for an ultramarathon, studying the latest medical findings, roadtripping, and launching a podcast about dog grooming with a master groomer. “We found parallels between medicine and dog grooming,” he says, somewhat convincingly.

Also working the ruff life is Jen Tserng, MD, a former forensic pathologist who landed on news websites in recent years for becoming a professional dogwalker and housesitter without a permanent home. Dr. Tserng knows doctors were restless and unhappy before COVID-19, their thoughts wandering where the grass might be greener.

As her profile grew, she found her inbox gathering messages from disaffected medical minions: students with a fear of failing or staring down residency application season and employed doctors sick of the constant grind. As she recounted those de facto life coach conversations (“What do you really enjoy?” “Do you really like dogs?”) by phone from New York, she said matter-of-factly, “They don’t call because of COVID. They call because they hate their lives.”

Michelle Mudge-Riley, MD, a physician in Texas, has been seeing this shift for some time as well. She recently held a virtual version of her Physicians Helping Physicians conference, where doctors hear from their peers working successfully in fields like pharmaceuticals and real estate investing.

When COVID-19 hit, Dr. Mudge-Riley quickly pivoted to a virtual platform, where the MDs and DOs huddled in breakout rooms having honest chats about their fears and tentative hopes about their new careers.

“There has been increased interest in nonclinical exploration into full- and part-time careers, as well as side hustles, since COVID began,” she said. “Many physicians have had their hours or pay cut, and some have been laid off. Others are furloughed. Some just want out of an environment where they don’t feel safe.”

An ear, nose, and throat surgeon, Maansi Doshi, MD, from central California, didn’t feel safe – so she left. She had returned from India sick with a mystery virus right as the pandemic began (she said her COVID-19 tests were all negative) and was waiting to get well enough to go back to her private practice job. However, she said she clashed with Trump-supporting colleagues she feared might not be taking the pandemic seriously enough.

Finally getting over a relapse of her mystery virus, Dr. Doshi emailed her resignation in May. Her husband, family practice doctor Mark Mangiapane, MD, gave his job notice weeks later in solidarity because he worked in the same building. Together, they have embraced gardening, a Peloton splurge, and learning business skills to open private practices – solo primary care for him; ENT with a focus on her favorite surgery, rhinoplasty, for her.

Dr. Mangiapane had considered editing medical brochures and also tried to apply for a job as a county public health officer in rural California, but he received his own shock when he learned the county intended to open schools in the midst of the pandemic despite advisement to the contrary by the former health officer.

He retreated from job listings altogether after hearing his would-be peers were getting death threats – targeting their children.

Both doctors felt COVID-19 pushed them beyond their comfort zones. “If COVID hadn’t happened, I would be working. ... Be ‘owned.’ In a weird way, COVID made me more independent and take a risk with my career.”

Obstetrician Kwandaa Roberts, MD, certainly did; she took a budding interest in decorating dollhouses straight to Instagram and national news fame, and she is now a TV-show expert on “Sell This House.”

Like Dr. Doshi and Dr. Mangiapane, Dr. Polak wants to be more in control of his future – even if selling T-shirts at a mall means a certain loss of status along the way.

“Aside from my passion to learn and to have that connection with people, I went into medicine ... because of the job security I thought existed,” he said. “I would say that my getting furloughed has changed my view of the United States in a dramatic way. I do not feel as confident in the U.S. economy and general way of life as I did a year ago. And I am taking a number of steps to put myself in a more fluid, adaptable position in case another crisis like this occurs or if the current state of things worsens.”

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

One of the biggest conundrums of the COVID-19 pandemic has been the simultaneous panic-hiring of medical professionals in hot spots and significant downsizing of staff across the country. From huge hospital systems to private practices, the stoppage of breast reductions and knee replacements, not to mention the drops in motor vehicle accidents and bar fights, have quieted operating rooms and emergency departments and put doctors’ jobs on the chopping block. A widely cited survey suggests that 21% of doctors have had a work reduction due to COVID-19.

For many American doctors, this is their first extended period of unemployment. Unlike engineers or those with MBAs who might see their fortunes rise and fall with the whims of recessions and boom times, physicians are not exactly accustomed to being laid off. However, doctors were already smarting for years due to falling salaries and decreased autonomy, punctuated by endless clicks on electronic medical records software.

Now, the twin shock of income loss and feeling unwanted in a pandemic – when, you know, medicine might seem especially essential – has doctors resorting to a bizarre array of side gigs, “fun-employment” activities, or outright career overhauls.

Stephanie Eschenbach Morgan, MD, a breast radiologist in North Carolina, trained for 10 years after college before earning a true physician’s salary.

“Being furloughed was awful. Initially, it was only going to be 2 weeks, and then it turned into 2 months with no pay,” she reflected.

Dr. Eschenbach Morgan and her surgeon husband, who lost a full quarter’s salary, had to ask for grace periods on their credit card and mortgage payments because they had paid a large tax bill right before the pandemic began. “We couldn’t get any stimulus help, so that added insult to injury,” she said.

With her time spent waiting in a holding pattern, Dr. Eschenbach Morgan homeschooled her two young children and started putting a home gym together. She went on a home organizing spree, started a garden, and, perhaps most impressively, caught up with 5 years of photo albums.

A bonus she noted: “I didn’t set an alarm for 2 months.”

Shella Farooki, MD, a radiologist in California, was also focused on homeschooling, itself a demanding job, and veered toward retirement. When one of her work contracts furloughed her (“at one point, I made $30K a month for [their business]”), she started saving money at home, teaching the kids, and applied for a Paycheck Protection Program loan. Her husband, a hospitalist, had had his shifts cut. Dr. Farooki tried a radiology artificial intelligence firm but backed out when she was asked to read 9,200 studies for them for $2,000 per month.

Now, she thinks about leaving medicine “every day.”

Some doctors are questioning whether they should be in medicine in the first place. Family medicine physician Jonathan Polak, MD, faced with his own pink slip, turned to pink T-shirts instead. His girlfriend manages an outlet of the teen fashion retailer Justice. Dr. Polak, who finished his residency just 2 years ago, didn’t hesitate to take a $10-an-hour gig as a stock doc, once even finding himself delivering a shelving unit from the shuttering store to a physician fleeing the city for rural New Hampshire to “escape.”

There’s no escape for him – yet. Saddled with “astronomical” student loans, he had considered grocery store work as well. Dr. Polak knows he can’t work part time or go into teaching long term, as he might like.

Even so, he’s doing everything he can to not be in patient care for the long haul – it’s just not what he thought it would be.

“The culture of medicine, bureaucracy, endless paperwork and charting, and threat of litigation sucks a lot of the joy out of it to the point that I don’t see myself doing it forever when imagining myself 5-10 years into it.”

Still, he recently took an 18-month hospital contract that will force him to move to Florida, but he’s also been turning himself into a veritable Renaissance man; composing music, training for an ultramarathon, studying the latest medical findings, roadtripping, and launching a podcast about dog grooming with a master groomer. “We found parallels between medicine and dog grooming,” he says, somewhat convincingly.

Also working the ruff life is Jen Tserng, MD, a former forensic pathologist who landed on news websites in recent years for becoming a professional dogwalker and housesitter without a permanent home. Dr. Tserng knows doctors were restless and unhappy before COVID-19, their thoughts wandering where the grass might be greener.

As her profile grew, she found her inbox gathering messages from disaffected medical minions: students with a fear of failing or staring down residency application season and employed doctors sick of the constant grind. As she recounted those de facto life coach conversations (“What do you really enjoy?” “Do you really like dogs?”) by phone from New York, she said matter-of-factly, “They don’t call because of COVID. They call because they hate their lives.”

Michelle Mudge-Riley, MD, a physician in Texas, has been seeing this shift for some time as well. She recently held a virtual version of her Physicians Helping Physicians conference, where doctors hear from their peers working successfully in fields like pharmaceuticals and real estate investing.

When COVID-19 hit, Dr. Mudge-Riley quickly pivoted to a virtual platform, where the MDs and DOs huddled in breakout rooms having honest chats about their fears and tentative hopes about their new careers.

“There has been increased interest in nonclinical exploration into full- and part-time careers, as well as side hustles, since COVID began,” she said. “Many physicians have had their hours or pay cut, and some have been laid off. Others are furloughed. Some just want out of an environment where they don’t feel safe.”

An ear, nose, and throat surgeon, Maansi Doshi, MD, from central California, didn’t feel safe – so she left. She had returned from India sick with a mystery virus right as the pandemic began (she said her COVID-19 tests were all negative) and was waiting to get well enough to go back to her private practice job. However, she said she clashed with Trump-supporting colleagues she feared might not be taking the pandemic seriously enough.

Finally getting over a relapse of her mystery virus, Dr. Doshi emailed her resignation in May. Her husband, family practice doctor Mark Mangiapane, MD, gave his job notice weeks later in solidarity because he worked in the same building. Together, they have embraced gardening, a Peloton splurge, and learning business skills to open private practices – solo primary care for him; ENT with a focus on her favorite surgery, rhinoplasty, for her.

Dr. Mangiapane had considered editing medical brochures and also tried to apply for a job as a county public health officer in rural California, but he received his own shock when he learned the county intended to open schools in the midst of the pandemic despite advisement to the contrary by the former health officer.

He retreated from job listings altogether after hearing his would-be peers were getting death threats – targeting their children.

Both doctors felt COVID-19 pushed them beyond their comfort zones. “If COVID hadn’t happened, I would be working. ... Be ‘owned.’ In a weird way, COVID made me more independent and take a risk with my career.”

Obstetrician Kwandaa Roberts, MD, certainly did; she took a budding interest in decorating dollhouses straight to Instagram and national news fame, and she is now a TV-show expert on “Sell This House.”

Like Dr. Doshi and Dr. Mangiapane, Dr. Polak wants to be more in control of his future – even if selling T-shirts at a mall means a certain loss of status along the way.

“Aside from my passion to learn and to have that connection with people, I went into medicine ... because of the job security I thought existed,” he said. “I would say that my getting furloughed has changed my view of the United States in a dramatic way. I do not feel as confident in the U.S. economy and general way of life as I did a year ago. And I am taking a number of steps to put myself in a more fluid, adaptable position in case another crisis like this occurs or if the current state of things worsens.”

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

Hospitalists across the United States have been and continue to be a critical part of our nation’s response to COVID-19. On National Hospitalist Day, Thursday, March 4, 2021, the Society of Hospital Medicine invites you to celebrate the individuals and teams that make up the hospital medicine community.

Courtesy Joseph Li

On this special day, SHM encourages you to share your story, showcase your team’s efforts to improve patient care, express your pride for the specialty, or share how you are making a difference in your hospital and in the lives of patients.

Here are just a few of the ways you can celebrate:

• Register for our live roundtable, featuring Mark Shapiro, MD, hospitalist and host of the Explore the Space podcast, and four hospitalist panelists, on March 4 at 7 p.m. ET/4 p.m. PT.
• Download shareable graphics, posters, Zoom backgrounds, and coloring book pages
• Enter our social media photo contest and follow the #HowWeHospitalist hashtag across all platforms
• Read special hospitalist profiles in the Hospitalist, including: Eric E. Howell, MD, MHM; Grace Huang, MD; Bridget McGrath, PA-C, FHM; and Harry Cho, MD, SFHM

Thank you for all you do and continue to do for hospital medicine. We hope you take some time today to celebrate you and your colleagues, as well as your commendable contributions to health care and the future of the specialty.

To learn more about National Hospitalist Day, visit hospitalmedicine.org/hospitalistday.




 

Hospitalists across the United States have been and continue to be a critical part of our nation’s response to COVID-19. On National Hospitalist Day, Thursday, March 4, 2021, the Society of Hospital Medicine invites you to celebrate the individuals and teams that make up the hospital medicine community.

Courtesy Joseph Li

On this special day, SHM encourages you to share your story, showcase your team’s efforts to improve patient care, express your pride for the specialty, or share how you are making a difference in your hospital and in the lives of patients.

Here are just a few of the ways you can celebrate:

• Register for our live roundtable, featuring Mark Shapiro, MD, hospitalist and host of the Explore the Space podcast, and four hospitalist panelists, on March 4 at 7 p.m. ET/4 p.m. PT.
• Download shareable graphics, posters, Zoom backgrounds, and coloring book pages
• Enter our social media photo contest and follow the #HowWeHospitalist hashtag across all platforms
• Read special hospitalist profiles in the Hospitalist, including: Eric E. Howell, MD, MHM; Grace Huang, MD; Bridget McGrath, PA-C, FHM; and Harry Cho, MD, SFHM

Thank you for all you do and continue to do for hospital medicine. We hope you take some time today to celebrate you and your colleagues, as well as your commendable contributions to health care and the future of the specialty.

To learn more about National Hospitalist Day, visit hospitalmedicine.org/hospitalistday.




 

Hospitalists across the United States have been and continue to be a critical part of our nation’s response to COVID-19. On National Hospitalist Day, Thursday, March 4, 2021, the Society of Hospital Medicine invites you to celebrate the individuals and teams that make up the hospital medicine community.

Courtesy Joseph Li

On this special day, SHM encourages you to share your story, showcase your team’s efforts to improve patient care, express your pride for the specialty, or share how you are making a difference in your hospital and in the lives of patients.

Here are just a few of the ways you can celebrate:

• Register for our live roundtable, featuring Mark Shapiro, MD, hospitalist and host of the Explore the Space podcast, and four hospitalist panelists, on March 4 at 7 p.m. ET/4 p.m. PT.
• Download shareable graphics, posters, Zoom backgrounds, and coloring book pages
• Enter our social media photo contest and follow the #HowWeHospitalist hashtag across all platforms
• Read special hospitalist profiles in the Hospitalist, including: Eric E. Howell, MD, MHM; Grace Huang, MD; Bridget McGrath, PA-C, FHM; and Harry Cho, MD, SFHM

Thank you for all you do and continue to do for hospital medicine. We hope you take some time today to celebrate you and your colleagues, as well as your commendable contributions to health care and the future of the specialty.

To learn more about National Hospitalist Day, visit hospitalmedicine.org/hospitalistday.




 

United Healthcare recently became the latest major insurer to offer a “virtual primary care service.” Initially, the service will be part of some employer-sponsored insurance plans in 11 states. United intends to expand its footprint next year.

United is using the platform and the medical group of American Well, a telehealth service, to provide virtual primary care. Besides minor acute care, United’s virtual service covers annual wellness visits, routine follow-ups for chronic conditions, lab tests, and specialist referrals with little or no cost sharing.

The giant insurer is now offering its virtual primary care plan in Arizona, Colorado, Illinois, Maryland, North Carolina, Ohio, South Carolina, Texas, Virginia, Washington, D.C., and West Virginia.

Other insurers are offering similar virtual primary care plans. For example, Humana has partnered with Doctor on Demand, and Cigna is working with MDLive to offer virtual primary care plans. Both of these plans encourage consumers to form ongoing relationships with physicians hired by the telehealth services. Similarly, Harvard Pilgrim, which has also joined with Doctor on Demand, said that consumers get “virtual PCPs” along with a full care team.

Humana has priced the premiums for its virtual service at about half the cost of Humana’s most popular traditional plan. There are no copays for telehealth visits; there are $5 copays for common lab tests and prescriptions. Cigna said that its virtual plan makes coverage “more affordable,” but doesn’t provide any specifics.

According to United spokeswoman Maria Shydlo, the insurer’s virtual primary care service is not cheaper than its traditional products.
 

Increased telehealth adoption

When the COVID-19 pandemic first struck last year, telehealth was a lifesaver for primary care practices. Physicians were able to treat half or more of their patients through telehealth, including video and phone consultations.

That initial romance with telehealth did not last. Today, telehealth represents 9% of adult primary care visits. However, that’s still a much higher percentage than before 2020, and telehealth has become a fixture of primary care.

Prior to the pandemic, telehealth services dominated the virtual care space. Some large groups experimented with having their doctors conduct virtual consults with their patients. Other physicians dabbled with telehealth or stayed out of it entirely because health plans paid much less for virtual visits than for in-person visits.

That began to change as more and more states passed laws requiring payment parity. (Today, 36 states do.) Then as the pandemic took hold, Medicare loosened its regulations, allowing coverage of telehealth everywhere and establishing parity. But it’s unclear what will happen after the public health emergency ends.

United and other insurers portray their virtual primary care plans as an effort to connect more consumers with primary care physicians. Having a relationship with a primary care doctor, United noted in a press release, increases access to care, including preventive services. Moreover, a United survey found that a quarter of respondents preferred a virtual relationship with a primary care doctor.
 

Physician have mostly positive but mixed reactions

This news organization interviewed several physicians who practice in states where United has introduced its new offering. Only one doctor had heard about it, and another, solo family physician Will Sawyer, MD, of Cincinnati no longer contracts with United. Nevertheless, they all had strong opinions about virtual primary care plans from United and other insurers.

Dr. Sawyer is a big proponent of telehealth and notes that it’s “incredibly convenient” for older people, many of whom are afraid to come to the office out of fear they might contract COVID-19. He has found that telehealth can be useful for many kinds of acute and chronic care. But he believes (although he admits he does not have evidence) that United started its virtual primary care service mainly to save money.

No to some kinds of telehealth doctors

The physicians we spoke with were unified in their opposition to virtual primary care plans that mainly use physicians hired by telehealth services. Dr. Sawyer noted that one-off consultations with telehealth doctors might be okay for urgent care. “But what we’re trying to do with patients is change their behavior for better health outcomes, and that doesn’t happen in these one-off contacts,” he said.

Even if a patient were able to develop an online relationship with a telehealth doctor, Dr. Basch said, there are any number of situations in which an in-person visit might be necessary. “Whether it’s a urologic visit, a cardiac visit, or an allergy visit, do I need to listen to you or put my hands on you to palpate your liver? Or is this just a conversation with someone I know to see how they’re doing, how they’re managing their meds? Ninety percent of a diagnosis is history.”

Although the virtual plans allow a telehealth physician to refer a patient to an in-network specialist for an office visit, this isn’t the same as their primary care physician asking them to come in to be examined.

Moreover, Dr. Basch noted, people with chronic conditions can’t be treated only virtually. “I wouldn’t say that primary care should be done predominantly through virtual visits. It may be okay for young and healthy patients, but not for older people with chronic conditions. There are times when they should see their doctor in person.”
 

What can be done via telehealth

On the other hand, Dr. Basch heartily approves of conducting routine follow-up visits virtually for patients with chronic diseases, as long as the physician knows the patient’s history. Telehealth can also be used to coach patients on exercise, nutrition, and other lifestyle changes.

Dr. Kubitschek estimates that around 40%-50% of primary care can be delivered through telehealth. But the remainder encompasses potentially serious conditions that should be diagnosed and treated in face-to-face encounters, he said. “For example, if a patient has abdominal pain, you have to examine the person to get a clue of what they’re talking about. The pains are often diffuse, but they might be painful locally, which could indicate a mass or a bladder distension.”

For that reason, he doesn’t support the idea of patients depending on telehealth doctors in virtual primary care plans. “These doctors would not be available to care for the patient in an urgent situation without sending them to a costly emergency room or urgent care clinic. In those settings, excess testing is done because of a lack of familiarity with the patient and his or her history and exam. I think a combination of in-person and telehealth visits presents the best circumstance for the patient and the physician. Having said that, I do believe that telehealth alone is better than no interaction with a health care provider.”
 

United approach can help with prevention

Donny Aga, MD, an internist with Kelsey-Seybold, a multispecialty group in Houston, has been a member of United’s virtual health advisory group for the past 2 years. In his view, United’s virtual primary care service is moving in the right direction by covering preventive and chronic care. Noting that 25%-30% of patients nationally have put off wellness and chronic care visits out of fear of COVID-19, he said that,“if health plans like United are willing to cover preventive services through telehealth, that will allow us to catch up on a lot of the needed screening tests and exams. So it’s a very positive step forward.”

On the other hand, he said, virtual plans that depend solely on telehealth doctors are not the way to manage chronic conditions. “Primary care is best done by your own primary care physician, not by someone who doesn’t know you from a distance.”

Regarding the virtual plans in which patients can establish relationships with telehealth physicians, Dr. Aga said that this approach can benefit some patients, especially those who live in rural areas and don’t have access to primary care. But there are drawbacks, including the telehealth providers’ lack of knowledge about local specialists.

“The negative is that you don’t have a [primary care physicians] who’s local, who knows you, who has examined you before, and who has a good relationship with those specialists and knows who is the right specialist to see for your problem,” Dr. Aga said. “It’s very difficult, if you don’t live and work in that area, to know the best places to send people.”
 

Virtual visits cost less

Like Dr. Basch, Dr. Aga said it’s possible that some insurance companies might begin to cover office visits only for certain conditions or services if they can be managed more cheaply via telehealth. He hopes that doesn’t happen; if it does, he predicts that patients and doctors will push back hard.

Why would a virtual primary care visit cost a health plan less than an in-person visit if it’s paying doctors the same for both? Dr. Aga said it’s because fewer prescriptions and lab tests are ordered in telehealth encounters. He bases this assertion on the quarter of a million virtual visits that Kelsey-Seybold has conducted and also alludes to published studies.

The characteristics of telehealth visits might explain this phenomenon, he said. “These visits are typically much shorter, and it’s easy to be problem-centric and problem based. Physicians use more of their intuitive skills, rather than just lab everybody up and get an x-ray, because that patient’s not there, and it’s easier to draw blood or get an x-ray if somebody is there.”
 

Cutting practice overhead

From the perspective of Kelsey-Seybold, which is now conducting about a fifth of its visits virtually, “infrastructure costs are less” for telehealth, Aga notes. Although Dr. Kubitschek and Dr. Sawyer say it doesn’t take less time to conduct a telehealth visit than an office visit, other practice costs may decrease in relationship to the percentage of a doctor’s visits that are virtual.

“If implemented appropriately, telehealth consults should cost less in terms of the ancillary costs surrounding care,” said Dr. Basch. He recalls that, some years ago, a five-doctor primary care group in Portland, Ore., began charging small monthly fees to patients for full-service care that included email access. After a while, 40% of their patients were coming in, and the rest received care by email or phone. As a result, the doctors were able to downsize to a smaller office space because they didn’t need a waiting room.

Although Dr. Basch doesn’t believe it would be appropriate for practices to do something like this in the midst of a pandemic, he sees the possibility of it happening in the future. “Eventually, a group might be able to say: ‘Yes, our practice expenses can be lower if we do this smartly. We could do as well as we’ve done on whatever insurance pays for office visits, knowing that we can deliver care to the same patient panel at, say, 10% lower overhead with telehealth.’ ”

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

United Healthcare recently became the latest major insurer to offer a “virtual primary care service.” Initially, the service will be part of some employer-sponsored insurance plans in 11 states. United intends to expand its footprint next year.

United is using the platform and the medical group of American Well, a telehealth service, to provide virtual primary care. Besides minor acute care, United’s virtual service covers annual wellness visits, routine follow-ups for chronic conditions, lab tests, and specialist referrals with little or no cost sharing.

The giant insurer is now offering its virtual primary care plan in Arizona, Colorado, Illinois, Maryland, North Carolina, Ohio, South Carolina, Texas, Virginia, Washington, D.C., and West Virginia.

Other insurers are offering similar virtual primary care plans. For example, Humana has partnered with Doctor on Demand, and Cigna is working with MDLive to offer virtual primary care plans. Both of these plans encourage consumers to form ongoing relationships with physicians hired by the telehealth services. Similarly, Harvard Pilgrim, which has also joined with Doctor on Demand, said that consumers get “virtual PCPs” along with a full care team.

Humana has priced the premiums for its virtual service at about half the cost of Humana’s most popular traditional plan. There are no copays for telehealth visits; there are $5 copays for common lab tests and prescriptions. Cigna said that its virtual plan makes coverage “more affordable,” but doesn’t provide any specifics.

According to United spokeswoman Maria Shydlo, the insurer’s virtual primary care service is not cheaper than its traditional products.
 

Increased telehealth adoption

When the COVID-19 pandemic first struck last year, telehealth was a lifesaver for primary care practices. Physicians were able to treat half or more of their patients through telehealth, including video and phone consultations.

That initial romance with telehealth did not last. Today, telehealth represents 9% of adult primary care visits. However, that’s still a much higher percentage than before 2020, and telehealth has become a fixture of primary care.

Prior to the pandemic, telehealth services dominated the virtual care space. Some large groups experimented with having their doctors conduct virtual consults with their patients. Other physicians dabbled with telehealth or stayed out of it entirely because health plans paid much less for virtual visits than for in-person visits.

That began to change as more and more states passed laws requiring payment parity. (Today, 36 states do.) Then as the pandemic took hold, Medicare loosened its regulations, allowing coverage of telehealth everywhere and establishing parity. But it’s unclear what will happen after the public health emergency ends.

United and other insurers portray their virtual primary care plans as an effort to connect more consumers with primary care physicians. Having a relationship with a primary care doctor, United noted in a press release, increases access to care, including preventive services. Moreover, a United survey found that a quarter of respondents preferred a virtual relationship with a primary care doctor.
 

Physician have mostly positive but mixed reactions

This news organization interviewed several physicians who practice in states where United has introduced its new offering. Only one doctor had heard about it, and another, solo family physician Will Sawyer, MD, of Cincinnati no longer contracts with United. Nevertheless, they all had strong opinions about virtual primary care plans from United and other insurers.

Dr. Sawyer is a big proponent of telehealth and notes that it’s “incredibly convenient” for older people, many of whom are afraid to come to the office out of fear they might contract COVID-19. He has found that telehealth can be useful for many kinds of acute and chronic care. But he believes (although he admits he does not have evidence) that United started its virtual primary care service mainly to save money.

No to some kinds of telehealth doctors

The physicians we spoke with were unified in their opposition to virtual primary care plans that mainly use physicians hired by telehealth services. Dr. Sawyer noted that one-off consultations with telehealth doctors might be okay for urgent care. “But what we’re trying to do with patients is change their behavior for better health outcomes, and that doesn’t happen in these one-off contacts,” he said.

Even if a patient were able to develop an online relationship with a telehealth doctor, Dr. Basch said, there are any number of situations in which an in-person visit might be necessary. “Whether it’s a urologic visit, a cardiac visit, or an allergy visit, do I need to listen to you or put my hands on you to palpate your liver? Or is this just a conversation with someone I know to see how they’re doing, how they’re managing their meds? Ninety percent of a diagnosis is history.”

Although the virtual plans allow a telehealth physician to refer a patient to an in-network specialist for an office visit, this isn’t the same as their primary care physician asking them to come in to be examined.

Moreover, Dr. Basch noted, people with chronic conditions can’t be treated only virtually. “I wouldn’t say that primary care should be done predominantly through virtual visits. It may be okay for young and healthy patients, but not for older people with chronic conditions. There are times when they should see their doctor in person.”
 

What can be done via telehealth

On the other hand, Dr. Basch heartily approves of conducting routine follow-up visits virtually for patients with chronic diseases, as long as the physician knows the patient’s history. Telehealth can also be used to coach patients on exercise, nutrition, and other lifestyle changes.

Dr. Kubitschek estimates that around 40%-50% of primary care can be delivered through telehealth. But the remainder encompasses potentially serious conditions that should be diagnosed and treated in face-to-face encounters, he said. “For example, if a patient has abdominal pain, you have to examine the person to get a clue of what they’re talking about. The pains are often diffuse, but they might be painful locally, which could indicate a mass or a bladder distension.”

For that reason, he doesn’t support the idea of patients depending on telehealth doctors in virtual primary care plans. “These doctors would not be available to care for the patient in an urgent situation without sending them to a costly emergency room or urgent care clinic. In those settings, excess testing is done because of a lack of familiarity with the patient and his or her history and exam. I think a combination of in-person and telehealth visits presents the best circumstance for the patient and the physician. Having said that, I do believe that telehealth alone is better than no interaction with a health care provider.”
 

United approach can help with prevention

Donny Aga, MD, an internist with Kelsey-Seybold, a multispecialty group in Houston, has been a member of United’s virtual health advisory group for the past 2 years. In his view, United’s virtual primary care service is moving in the right direction by covering preventive and chronic care. Noting that 25%-30% of patients nationally have put off wellness and chronic care visits out of fear of COVID-19, he said that,“if health plans like United are willing to cover preventive services through telehealth, that will allow us to catch up on a lot of the needed screening tests and exams. So it’s a very positive step forward.”

On the other hand, he said, virtual plans that depend solely on telehealth doctors are not the way to manage chronic conditions. “Primary care is best done by your own primary care physician, not by someone who doesn’t know you from a distance.”

Regarding the virtual plans in which patients can establish relationships with telehealth physicians, Dr. Aga said that this approach can benefit some patients, especially those who live in rural areas and don’t have access to primary care. But there are drawbacks, including the telehealth providers’ lack of knowledge about local specialists.

“The negative is that you don’t have a [primary care physicians] who’s local, who knows you, who has examined you before, and who has a good relationship with those specialists and knows who is the right specialist to see for your problem,” Dr. Aga said. “It’s very difficult, if you don’t live and work in that area, to know the best places to send people.”
 

Virtual visits cost less

Like Dr. Basch, Dr. Aga said it’s possible that some insurance companies might begin to cover office visits only for certain conditions or services if they can be managed more cheaply via telehealth. He hopes that doesn’t happen; if it does, he predicts that patients and doctors will push back hard.

Why would a virtual primary care visit cost a health plan less than an in-person visit if it’s paying doctors the same for both? Dr. Aga said it’s because fewer prescriptions and lab tests are ordered in telehealth encounters. He bases this assertion on the quarter of a million virtual visits that Kelsey-Seybold has conducted and also alludes to published studies.

The characteristics of telehealth visits might explain this phenomenon, he said. “These visits are typically much shorter, and it’s easy to be problem-centric and problem based. Physicians use more of their intuitive skills, rather than just lab everybody up and get an x-ray, because that patient’s not there, and it’s easier to draw blood or get an x-ray if somebody is there.”
 

Cutting practice overhead

From the perspective of Kelsey-Seybold, which is now conducting about a fifth of its visits virtually, “infrastructure costs are less” for telehealth, Aga notes. Although Dr. Kubitschek and Dr. Sawyer say it doesn’t take less time to conduct a telehealth visit than an office visit, other practice costs may decrease in relationship to the percentage of a doctor’s visits that are virtual.

“If implemented appropriately, telehealth consults should cost less in terms of the ancillary costs surrounding care,” said Dr. Basch. He recalls that, some years ago, a five-doctor primary care group in Portland, Ore., began charging small monthly fees to patients for full-service care that included email access. After a while, 40% of their patients were coming in, and the rest received care by email or phone. As a result, the doctors were able to downsize to a smaller office space because they didn’t need a waiting room.

Although Dr. Basch doesn’t believe it would be appropriate for practices to do something like this in the midst of a pandemic, he sees the possibility of it happening in the future. “Eventually, a group might be able to say: ‘Yes, our practice expenses can be lower if we do this smartly. We could do as well as we’ve done on whatever insurance pays for office visits, knowing that we can deliver care to the same patient panel at, say, 10% lower overhead with telehealth.’ ”

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

United Healthcare recently became the latest major insurer to offer a “virtual primary care service.” Initially, the service will be part of some employer-sponsored insurance plans in 11 states. United intends to expand its footprint next year.

United is using the platform and the medical group of American Well, a telehealth service, to provide virtual primary care. Besides minor acute care, United’s virtual service covers annual wellness visits, routine follow-ups for chronic conditions, lab tests, and specialist referrals with little or no cost sharing.

The giant insurer is now offering its virtual primary care plan in Arizona, Colorado, Illinois, Maryland, North Carolina, Ohio, South Carolina, Texas, Virginia, Washington, D.C., and West Virginia.

Other insurers are offering similar virtual primary care plans. For example, Humana has partnered with Doctor on Demand, and Cigna is working with MDLive to offer virtual primary care plans. Both of these plans encourage consumers to form ongoing relationships with physicians hired by the telehealth services. Similarly, Harvard Pilgrim, which has also joined with Doctor on Demand, said that consumers get “virtual PCPs” along with a full care team.

Humana has priced the premiums for its virtual service at about half the cost of Humana’s most popular traditional plan. There are no copays for telehealth visits; there are $5 copays for common lab tests and prescriptions. Cigna said that its virtual plan makes coverage “more affordable,” but doesn’t provide any specifics.

According to United spokeswoman Maria Shydlo, the insurer’s virtual primary care service is not cheaper than its traditional products.
 

Increased telehealth adoption

When the COVID-19 pandemic first struck last year, telehealth was a lifesaver for primary care practices. Physicians were able to treat half or more of their patients through telehealth, including video and phone consultations.

That initial romance with telehealth did not last. Today, telehealth represents 9% of adult primary care visits. However, that’s still a much higher percentage than before 2020, and telehealth has become a fixture of primary care.

Prior to the pandemic, telehealth services dominated the virtual care space. Some large groups experimented with having their doctors conduct virtual consults with their patients. Other physicians dabbled with telehealth or stayed out of it entirely because health plans paid much less for virtual visits than for in-person visits.

That began to change as more and more states passed laws requiring payment parity. (Today, 36 states do.) Then as the pandemic took hold, Medicare loosened its regulations, allowing coverage of telehealth everywhere and establishing parity. But it’s unclear what will happen after the public health emergency ends.

United and other insurers portray their virtual primary care plans as an effort to connect more consumers with primary care physicians. Having a relationship with a primary care doctor, United noted in a press release, increases access to care, including preventive services. Moreover, a United survey found that a quarter of respondents preferred a virtual relationship with a primary care doctor.
 

Physician have mostly positive but mixed reactions

This news organization interviewed several physicians who practice in states where United has introduced its new offering. Only one doctor had heard about it, and another, solo family physician Will Sawyer, MD, of Cincinnati no longer contracts with United. Nevertheless, they all had strong opinions about virtual primary care plans from United and other insurers.

Dr. Sawyer is a big proponent of telehealth and notes that it’s “incredibly convenient” for older people, many of whom are afraid to come to the office out of fear they might contract COVID-19. He has found that telehealth can be useful for many kinds of acute and chronic care. But he believes (although he admits he does not have evidence) that United started its virtual primary care service mainly to save money.

No to some kinds of telehealth doctors

The physicians we spoke with were unified in their opposition to virtual primary care plans that mainly use physicians hired by telehealth services. Dr. Sawyer noted that one-off consultations with telehealth doctors might be okay for urgent care. “But what we’re trying to do with patients is change their behavior for better health outcomes, and that doesn’t happen in these one-off contacts,” he said.

Even if a patient were able to develop an online relationship with a telehealth doctor, Dr. Basch said, there are any number of situations in which an in-person visit might be necessary. “Whether it’s a urologic visit, a cardiac visit, or an allergy visit, do I need to listen to you or put my hands on you to palpate your liver? Or is this just a conversation with someone I know to see how they’re doing, how they’re managing their meds? Ninety percent of a diagnosis is history.”

Although the virtual plans allow a telehealth physician to refer a patient to an in-network specialist for an office visit, this isn’t the same as their primary care physician asking them to come in to be examined.

Moreover, Dr. Basch noted, people with chronic conditions can’t be treated only virtually. “I wouldn’t say that primary care should be done predominantly through virtual visits. It may be okay for young and healthy patients, but not for older people with chronic conditions. There are times when they should see their doctor in person.”
 

What can be done via telehealth

On the other hand, Dr. Basch heartily approves of conducting routine follow-up visits virtually for patients with chronic diseases, as long as the physician knows the patient’s history. Telehealth can also be used to coach patients on exercise, nutrition, and other lifestyle changes.

Dr. Kubitschek estimates that around 40%-50% of primary care can be delivered through telehealth. But the remainder encompasses potentially serious conditions that should be diagnosed and treated in face-to-face encounters, he said. “For example, if a patient has abdominal pain, you have to examine the person to get a clue of what they’re talking about. The pains are often diffuse, but they might be painful locally, which could indicate a mass or a bladder distension.”

For that reason, he doesn’t support the idea of patients depending on telehealth doctors in virtual primary care plans. “These doctors would not be available to care for the patient in an urgent situation without sending them to a costly emergency room or urgent care clinic. In those settings, excess testing is done because of a lack of familiarity with the patient and his or her history and exam. I think a combination of in-person and telehealth visits presents the best circumstance for the patient and the physician. Having said that, I do believe that telehealth alone is better than no interaction with a health care provider.”
 

United approach can help with prevention

Donny Aga, MD, an internist with Kelsey-Seybold, a multispecialty group in Houston, has been a member of United’s virtual health advisory group for the past 2 years. In his view, United’s virtual primary care service is moving in the right direction by covering preventive and chronic care. Noting that 25%-30% of patients nationally have put off wellness and chronic care visits out of fear of COVID-19, he said that,“if health plans like United are willing to cover preventive services through telehealth, that will allow us to catch up on a lot of the needed screening tests and exams. So it’s a very positive step forward.”

On the other hand, he said, virtual plans that depend solely on telehealth doctors are not the way to manage chronic conditions. “Primary care is best done by your own primary care physician, not by someone who doesn’t know you from a distance.”

Regarding the virtual plans in which patients can establish relationships with telehealth physicians, Dr. Aga said that this approach can benefit some patients, especially those who live in rural areas and don’t have access to primary care. But there are drawbacks, including the telehealth providers’ lack of knowledge about local specialists.

“The negative is that you don’t have a [primary care physicians] who’s local, who knows you, who has examined you before, and who has a good relationship with those specialists and knows who is the right specialist to see for your problem,” Dr. Aga said. “It’s very difficult, if you don’t live and work in that area, to know the best places to send people.”
 

Virtual visits cost less

Like Dr. Basch, Dr. Aga said it’s possible that some insurance companies might begin to cover office visits only for certain conditions or services if they can be managed more cheaply via telehealth. He hopes that doesn’t happen; if it does, he predicts that patients and doctors will push back hard.

Why would a virtual primary care visit cost a health plan less than an in-person visit if it’s paying doctors the same for both? Dr. Aga said it’s because fewer prescriptions and lab tests are ordered in telehealth encounters. He bases this assertion on the quarter of a million virtual visits that Kelsey-Seybold has conducted and also alludes to published studies.

The characteristics of telehealth visits might explain this phenomenon, he said. “These visits are typically much shorter, and it’s easy to be problem-centric and problem based. Physicians use more of their intuitive skills, rather than just lab everybody up and get an x-ray, because that patient’s not there, and it’s easier to draw blood or get an x-ray if somebody is there.”
 

Cutting practice overhead

From the perspective of Kelsey-Seybold, which is now conducting about a fifth of its visits virtually, “infrastructure costs are less” for telehealth, Aga notes. Although Dr. Kubitschek and Dr. Sawyer say it doesn’t take less time to conduct a telehealth visit than an office visit, other practice costs may decrease in relationship to the percentage of a doctor’s visits that are virtual.

“If implemented appropriately, telehealth consults should cost less in terms of the ancillary costs surrounding care,” said Dr. Basch. He recalls that, some years ago, a five-doctor primary care group in Portland, Ore., began charging small monthly fees to patients for full-service care that included email access. After a while, 40% of their patients were coming in, and the rest received care by email or phone. As a result, the doctors were able to downsize to a smaller office space because they didn’t need a waiting room.

Although Dr. Basch doesn’t believe it would be appropriate for practices to do something like this in the midst of a pandemic, he sees the possibility of it happening in the future. “Eventually, a group might be able to say: ‘Yes, our practice expenses can be lower if we do this smartly. We could do as well as we’ve done on whatever insurance pays for office visits, knowing that we can deliver care to the same patient panel at, say, 10% lower overhead with telehealth.’ ”

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

Editor’s note: This profile is part of the Society of Hospital Medicine’s celebration of National Hospitalist Day on March 4. National Hospitalist Day occurs the first Thursday in March annually and celebrates the fastest growing specialty in modern medicine and hospitalists’ enduring contributions to the evolving health care landscape.

Bridget McGrath, PA-C, FHM, is a physician assistant and director of the nurse practitioner/physician assistant service line for the section of hospital medicine at the University of Chicago. She is a cochair of SHM’s NP/PA Special Interest Group.

Where did you receive your PA education/training? Was your intention always to be a PA?

I graduated from the PA program at Butler University, Indianapolis, in 2014. In college, whenever I shadowed a PA, I was always impressed that each one loved their job and said they would never change it. That universal passion for the PA profession really made an impression on me.

At what point in your PA education/training did you decide to practice hospital medicine? What about it appealed to you?

That occurred during my clinical rotation year at Butler. I had always thought I wanted to practice neonatology, but during my clinical rotation I really fell in love with adult medicine. I recall that during my clinical rotation, the preceptor said to me that the goal was not to have me understand every aspect of medicine, but to learn how to exist in a hospital setting. I was exposed to the breadth of hospital medicine practice and I fell in love with the complexity, the variety, and the environment itself.

I initially accepted a job as a med-peds hospitalist PA – which brought both of my passions together at that time – at Schneck Medical Center in Seymour, Ind. During that time, Schneck was a 100-bed rural community hospital which had recently been the recipient of the Malcolm Baldrige National Quality Award. It was there that I was able to practice with a phenomenal group of physicians, nurses, and social workers who really took me under their wing and taught me how to be a hospitalist PA. I practiced at Schneck for 3 years, and then moved to the University of Chicago in 2017.

I am now the director of NP/PA services for the section of hospital medicine, overseeing a group of seven on our NP/PA team, within a larger group of about 60 physicians.
 

What are your favorite areas of clinical practice?

Like many hospitalists, I enjoy the variety of medicine that hospitalists practice. One area that I find especially rewarding is my time in our transplant comanagement services. To be able to walk with patients on their transplant journey is very rewarding, and I am very appreciative of the mentoring I have received from some of my colleagues with a deeper understanding of transplant medicine.

In my administrative role, I have the privilege of helping to expand the professional education and training of my colleagues. I have a passion for medical education, and we have been working to develop interprofessional educational opportunities within our section. I have had time to think about the imprint of NPs and PAs in academic medicine, and how we can continue to meet the professional educational needs of our section while improving the care of our patients.
 

What are the most challenging aspects of practicing hospital medicine?

The volume of diagnoses that we are expected to manage on a daily basis can be challenging. This challenges you to continue learning. The complexity of discharge planning, particularly for patients in underserved communities, can also be challenging. You have to make sure your patients are ready mentally, physically and emotionally for discharge. As a hospitalist, you are continuously thinking about how to optimize patients to leave your care. For example, patients have different insurance situations, different access to care at home – you are always managing the medical needs of your patient in the context of these other issues.

How does a hospitalist PA work differently from a PA in other care settings?

We are meant to be generalists. We serve as the main provider in owning our patients’ care. A hospitalist PA serves as a cog in the wheel, with connections to specialists, consultants, nurses, social workers, pharmacists, etc., and we are tasked with synthesizing all aspects of patient care to ensure the best outcome.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Each hospital medicine group will know how to best integrate their NPs and PAs based on the skillsets of their NPs and PAs, and the needs of the section and the hospital. I personally feel that the best way to utilize NPs and PAs is to allow them to own all aspects of patient care and work at the highest scope of practice. By doing this you empower the NP or PA to continue to develop their skill set and set a precedent of collaboration and respect for interprofessional care models within your section’s culture.

Scope of practice for an NP or PA is going to be based on a conglomeration of roles and bylaws. We are certified nationally, and our scope of practice is determined at the state level and the hospital by level. For the individual NP and PA, it really depends on the hospital medicine group, and how well a practice incorporates a sense of collegiality.
 

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

There are a few key things that need to happen in order for hospital medicine groups to set up their NPs and PAs for success. The first is for PAs to have exposure to inpatient rotations during clinical rotations. A hospital medicine group also should have a very intentional onboarding process for NPs and PAs. They should also establish a culture of acceptance. To do this, they should utilize resources like SHM’s NP/PA Hospital Medicine Onboarding Toolkit and the SHM/American Academy of Physician Assistants Hospitalist Bootcamp On Demand.

Mentoring is also remarkably important. I have been incredibly blessed to have mentors that helped make me into the PA that I am. I could not have done what I did in the field without people taking a chance on me, and it is important to pass that on to the next generation of PAs.
 

How has COVID-19 changed the practice of hospital medicine, specifically for advanced practice providers?

The pandemic has demonstrated opportunities for teamwork and utilization of NPs and PAs. The COVID pandemic forced everyone to reflect on why they originally got into medicine – to help patients. I think there will be many doors opening for NPs and PAs, and many pathways for leadership.

The hospitalist leadership at the University of Chicago truly identified that we needed to make wellness a main priority during the beginning of the pandemic. We developed a wellness work group that I have been coleading.
 

What’s on the horizon for NPs and PAs in hospital medicine?

We are seeing significant increases in hospitalist program utilization, so this is a time where NPs and PAs can be advocates for our profession and articulate how we can use our backgrounds and training to build better care models in order to meet the needs of our patients.

I hope we will see more NPs and PAs assuming leadership roles to ensure that our voices are heard. We should also be advocating for more collaboration and teamwork with our MD and DO colleagues.
 

Do you have any advice for PA students interested in hospital medicine?

I always tell my students that they should be sponges – you are not expected to know everything as a hospitalist PA, but you are expected to continue learning in order to develop into the best PA you can be. Always be open to where your career path can take you. Hospital medicine is a relatively young field within medicine, and the diversity of our field is very exciting looking forward.

Editor’s note: This profile is part of the Society of Hospital Medicine’s celebration of National Hospitalist Day on March 4. National Hospitalist Day occurs the first Thursday in March annually and celebrates the fastest growing specialty in modern medicine and hospitalists’ enduring contributions to the evolving health care landscape.

Bridget McGrath, PA-C, FHM, is a physician assistant and director of the nurse practitioner/physician assistant service line for the section of hospital medicine at the University of Chicago. She is a cochair of SHM’s NP/PA Special Interest Group.

Where did you receive your PA education/training? Was your intention always to be a PA?

I graduated from the PA program at Butler University, Indianapolis, in 2014. In college, whenever I shadowed a PA, I was always impressed that each one loved their job and said they would never change it. That universal passion for the PA profession really made an impression on me.

At what point in your PA education/training did you decide to practice hospital medicine? What about it appealed to you?

That occurred during my clinical rotation year at Butler. I had always thought I wanted to practice neonatology, but during my clinical rotation I really fell in love with adult medicine. I recall that during my clinical rotation, the preceptor said to me that the goal was not to have me understand every aspect of medicine, but to learn how to exist in a hospital setting. I was exposed to the breadth of hospital medicine practice and I fell in love with the complexity, the variety, and the environment itself.

I initially accepted a job as a med-peds hospitalist PA – which brought both of my passions together at that time – at Schneck Medical Center in Seymour, Ind. During that time, Schneck was a 100-bed rural community hospital which had recently been the recipient of the Malcolm Baldrige National Quality Award. It was there that I was able to practice with a phenomenal group of physicians, nurses, and social workers who really took me under their wing and taught me how to be a hospitalist PA. I practiced at Schneck for 3 years, and then moved to the University of Chicago in 2017.

I am now the director of NP/PA services for the section of hospital medicine, overseeing a group of seven on our NP/PA team, within a larger group of about 60 physicians.
 

What are your favorite areas of clinical practice?

Like many hospitalists, I enjoy the variety of medicine that hospitalists practice. One area that I find especially rewarding is my time in our transplant comanagement services. To be able to walk with patients on their transplant journey is very rewarding, and I am very appreciative of the mentoring I have received from some of my colleagues with a deeper understanding of transplant medicine.

In my administrative role, I have the privilege of helping to expand the professional education and training of my colleagues. I have a passion for medical education, and we have been working to develop interprofessional educational opportunities within our section. I have had time to think about the imprint of NPs and PAs in academic medicine, and how we can continue to meet the professional educational needs of our section while improving the care of our patients.
 

What are the most challenging aspects of practicing hospital medicine?

The volume of diagnoses that we are expected to manage on a daily basis can be challenging. This challenges you to continue learning. The complexity of discharge planning, particularly for patients in underserved communities, can also be challenging. You have to make sure your patients are ready mentally, physically and emotionally for discharge. As a hospitalist, you are continuously thinking about how to optimize patients to leave your care. For example, patients have different insurance situations, different access to care at home – you are always managing the medical needs of your patient in the context of these other issues.

How does a hospitalist PA work differently from a PA in other care settings?

We are meant to be generalists. We serve as the main provider in owning our patients’ care. A hospitalist PA serves as a cog in the wheel, with connections to specialists, consultants, nurses, social workers, pharmacists, etc., and we are tasked with synthesizing all aspects of patient care to ensure the best outcome.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Each hospital medicine group will know how to best integrate their NPs and PAs based on the skillsets of their NPs and PAs, and the needs of the section and the hospital. I personally feel that the best way to utilize NPs and PAs is to allow them to own all aspects of patient care and work at the highest scope of practice. By doing this you empower the NP or PA to continue to develop their skill set and set a precedent of collaboration and respect for interprofessional care models within your section’s culture.

Scope of practice for an NP or PA is going to be based on a conglomeration of roles and bylaws. We are certified nationally, and our scope of practice is determined at the state level and the hospital by level. For the individual NP and PA, it really depends on the hospital medicine group, and how well a practice incorporates a sense of collegiality.
 

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

There are a few key things that need to happen in order for hospital medicine groups to set up their NPs and PAs for success. The first is for PAs to have exposure to inpatient rotations during clinical rotations. A hospital medicine group also should have a very intentional onboarding process for NPs and PAs. They should also establish a culture of acceptance. To do this, they should utilize resources like SHM’s NP/PA Hospital Medicine Onboarding Toolkit and the SHM/American Academy of Physician Assistants Hospitalist Bootcamp On Demand.

Mentoring is also remarkably important. I have been incredibly blessed to have mentors that helped make me into the PA that I am. I could not have done what I did in the field without people taking a chance on me, and it is important to pass that on to the next generation of PAs.
 

How has COVID-19 changed the practice of hospital medicine, specifically for advanced practice providers?

The pandemic has demonstrated opportunities for teamwork and utilization of NPs and PAs. The COVID pandemic forced everyone to reflect on why they originally got into medicine – to help patients. I think there will be many doors opening for NPs and PAs, and many pathways for leadership.

The hospitalist leadership at the University of Chicago truly identified that we needed to make wellness a main priority during the beginning of the pandemic. We developed a wellness work group that I have been coleading.
 

What’s on the horizon for NPs and PAs in hospital medicine?

We are seeing significant increases in hospitalist program utilization, so this is a time where NPs and PAs can be advocates for our profession and articulate how we can use our backgrounds and training to build better care models in order to meet the needs of our patients.

I hope we will see more NPs and PAs assuming leadership roles to ensure that our voices are heard. We should also be advocating for more collaboration and teamwork with our MD and DO colleagues.
 

Do you have any advice for PA students interested in hospital medicine?

I always tell my students that they should be sponges – you are not expected to know everything as a hospitalist PA, but you are expected to continue learning in order to develop into the best PA you can be. Always be open to where your career path can take you. Hospital medicine is a relatively young field within medicine, and the diversity of our field is very exciting looking forward.

Editor’s note: This profile is part of the Society of Hospital Medicine’s celebration of National Hospitalist Day on March 4. National Hospitalist Day occurs the first Thursday in March annually and celebrates the fastest growing specialty in modern medicine and hospitalists’ enduring contributions to the evolving health care landscape.

Bridget McGrath, PA-C, FHM, is a physician assistant and director of the nurse practitioner/physician assistant service line for the section of hospital medicine at the University of Chicago. She is a cochair of SHM’s NP/PA Special Interest Group.

Where did you receive your PA education/training? Was your intention always to be a PA?

I graduated from the PA program at Butler University, Indianapolis, in 2014. In college, whenever I shadowed a PA, I was always impressed that each one loved their job and said they would never change it. That universal passion for the PA profession really made an impression on me.

At what point in your PA education/training did you decide to practice hospital medicine? What about it appealed to you?

That occurred during my clinical rotation year at Butler. I had always thought I wanted to practice neonatology, but during my clinical rotation I really fell in love with adult medicine. I recall that during my clinical rotation, the preceptor said to me that the goal was not to have me understand every aspect of medicine, but to learn how to exist in a hospital setting. I was exposed to the breadth of hospital medicine practice and I fell in love with the complexity, the variety, and the environment itself.

I initially accepted a job as a med-peds hospitalist PA – which brought both of my passions together at that time – at Schneck Medical Center in Seymour, Ind. During that time, Schneck was a 100-bed rural community hospital which had recently been the recipient of the Malcolm Baldrige National Quality Award. It was there that I was able to practice with a phenomenal group of physicians, nurses, and social workers who really took me under their wing and taught me how to be a hospitalist PA. I practiced at Schneck for 3 years, and then moved to the University of Chicago in 2017.

I am now the director of NP/PA services for the section of hospital medicine, overseeing a group of seven on our NP/PA team, within a larger group of about 60 physicians.
 

What are your favorite areas of clinical practice?

Like many hospitalists, I enjoy the variety of medicine that hospitalists practice. One area that I find especially rewarding is my time in our transplant comanagement services. To be able to walk with patients on their transplant journey is very rewarding, and I am very appreciative of the mentoring I have received from some of my colleagues with a deeper understanding of transplant medicine.

In my administrative role, I have the privilege of helping to expand the professional education and training of my colleagues. I have a passion for medical education, and we have been working to develop interprofessional educational opportunities within our section. I have had time to think about the imprint of NPs and PAs in academic medicine, and how we can continue to meet the professional educational needs of our section while improving the care of our patients.
 

What are the most challenging aspects of practicing hospital medicine?

The volume of diagnoses that we are expected to manage on a daily basis can be challenging. This challenges you to continue learning. The complexity of discharge planning, particularly for patients in underserved communities, can also be challenging. You have to make sure your patients are ready mentally, physically and emotionally for discharge. As a hospitalist, you are continuously thinking about how to optimize patients to leave your care. For example, patients have different insurance situations, different access to care at home – you are always managing the medical needs of your patient in the context of these other issues.

How does a hospitalist PA work differently from a PA in other care settings?

We are meant to be generalists. We serve as the main provider in owning our patients’ care. A hospitalist PA serves as a cog in the wheel, with connections to specialists, consultants, nurses, social workers, pharmacists, etc., and we are tasked with synthesizing all aspects of patient care to ensure the best outcome.

What has your experience taught you about how NPs and PAs can best fit into hospital medicine groups?

Each hospital medicine group will know how to best integrate their NPs and PAs based on the skillsets of their NPs and PAs, and the needs of the section and the hospital. I personally feel that the best way to utilize NPs and PAs is to allow them to own all aspects of patient care and work at the highest scope of practice. By doing this you empower the NP or PA to continue to develop their skill set and set a precedent of collaboration and respect for interprofessional care models within your section’s culture.

Scope of practice for an NP or PA is going to be based on a conglomeration of roles and bylaws. We are certified nationally, and our scope of practice is determined at the state level and the hospital by level. For the individual NP and PA, it really depends on the hospital medicine group, and how well a practice incorporates a sense of collegiality.
 

What kind of resources do hospitalist PAs need to succeed, either from SHM or from their own institutions?

There are a few key things that need to happen in order for hospital medicine groups to set up their NPs and PAs for success. The first is for PAs to have exposure to inpatient rotations during clinical rotations. A hospital medicine group also should have a very intentional onboarding process for NPs and PAs. They should also establish a culture of acceptance. To do this, they should utilize resources like SHM’s NP/PA Hospital Medicine Onboarding Toolkit and the SHM/American Academy of Physician Assistants Hospitalist Bootcamp On Demand.

Mentoring is also remarkably important. I have been incredibly blessed to have mentors that helped make me into the PA that I am. I could not have done what I did in the field without people taking a chance on me, and it is important to pass that on to the next generation of PAs.
 

How has COVID-19 changed the practice of hospital medicine, specifically for advanced practice providers?

The pandemic has demonstrated opportunities for teamwork and utilization of NPs and PAs. The COVID pandemic forced everyone to reflect on why they originally got into medicine – to help patients. I think there will be many doors opening for NPs and PAs, and many pathways for leadership.

The hospitalist leadership at the University of Chicago truly identified that we needed to make wellness a main priority during the beginning of the pandemic. We developed a wellness work group that I have been coleading.
 

What’s on the horizon for NPs and PAs in hospital medicine?

We are seeing significant increases in hospitalist program utilization, so this is a time where NPs and PAs can be advocates for our profession and articulate how we can use our backgrounds and training to build better care models in order to meet the needs of our patients.

I hope we will see more NPs and PAs assuming leadership roles to ensure that our voices are heard. We should also be advocating for more collaboration and teamwork with our MD and DO colleagues.
 

Do you have any advice for PA students interested in hospital medicine?

I always tell my students that they should be sponges – you are not expected to know everything as a hospitalist PA, but you are expected to continue learning in order to develop into the best PA you can be. Always be open to where your career path can take you. Hospital medicine is a relatively young field within medicine, and the diversity of our field is very exciting looking forward.

In honor of National Hospitalist Day, the Society of Hospital Medicine and the Explore the Space podcast are teaming up to bring you a roundtable discussion, featuring a diverse group of hospitalists from all stages in their careers, on Thursday, March 4, at 7 p.m. ET / 4 p.m. PT.

Registration is required. Sign up here.

Hosted by Mark Shapiro, MD, hospitalist and founder, producer, and host of Explore the Space, the roundtable will include:

• Gurpreet Dhaliwal, MD, a clinician-educator and professor of medicine at the University of California, San Francisco. He studies, writes, and speaks about how doctors think – how they make diagnoses, how they develop diagnostic expertise, and what motivates them to improve their practice and the systems in which they work.
• Anika Kumar, MD, FHM, a clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine, and a pediatric hospitalist at Cleveland Clinic Children’s. She also serves as the pediatric editor of the Hospitalist, SHM’s monthly news magazine.
• Maylyn S. Martinez, MD, a clinician-researcher and clinical associate at the University of Chicago. Her research focuses on hospital-associated disability and she recently authored a perspectives piece in the Journal of Hospital Medicine with her mentor, Vineet Arora, MD, MHM, on why the COVID-19 pandemic might exacerbate this problem.
• Ndidi Unaka, MD, MEd, an associate professor in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. Dr. Unaka has served as the associate program director of the pediatric residency program since 2011. She is also the medical director of an inpatient unit that serves as the primary home.

For more information about SHM, please visit hospitalmedicine.org. To learn more about Explore the Space, please visit explorethespaceshow.com.

Register now.




 

In honor of National Hospitalist Day, the Society of Hospital Medicine and the Explore the Space podcast are teaming up to bring you a roundtable discussion, featuring a diverse group of hospitalists from all stages in their careers, on Thursday, March 4, at 7 p.m. ET / 4 p.m. PT.

Registration is required. Sign up here.

Hosted by Mark Shapiro, MD, hospitalist and founder, producer, and host of Explore the Space, the roundtable will include:

• Gurpreet Dhaliwal, MD, a clinician-educator and professor of medicine at the University of California, San Francisco. He studies, writes, and speaks about how doctors think – how they make diagnoses, how they develop diagnostic expertise, and what motivates them to improve their practice and the systems in which they work.
• Anika Kumar, MD, FHM, a clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine, and a pediatric hospitalist at Cleveland Clinic Children’s. She also serves as the pediatric editor of the Hospitalist, SHM’s monthly news magazine.
• Maylyn S. Martinez, MD, a clinician-researcher and clinical associate at the University of Chicago. Her research focuses on hospital-associated disability and she recently authored a perspectives piece in the Journal of Hospital Medicine with her mentor, Vineet Arora, MD, MHM, on why the COVID-19 pandemic might exacerbate this problem.
• Ndidi Unaka, MD, MEd, an associate professor in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. Dr. Unaka has served as the associate program director of the pediatric residency program since 2011. She is also the medical director of an inpatient unit that serves as the primary home.

For more information about SHM, please visit hospitalmedicine.org. To learn more about Explore the Space, please visit explorethespaceshow.com.

Register now.




 

In honor of National Hospitalist Day, the Society of Hospital Medicine and the Explore the Space podcast are teaming up to bring you a roundtable discussion, featuring a diverse group of hospitalists from all stages in their careers, on Thursday, March 4, at 7 p.m. ET / 4 p.m. PT.

Registration is required. Sign up here.

Hosted by Mark Shapiro, MD, hospitalist and founder, producer, and host of Explore the Space, the roundtable will include:

• Gurpreet Dhaliwal, MD, a clinician-educator and professor of medicine at the University of California, San Francisco. He studies, writes, and speaks about how doctors think – how they make diagnoses, how they develop diagnostic expertise, and what motivates them to improve their practice and the systems in which they work.
• Anika Kumar, MD, FHM, a clinical assistant professor of pediatrics at the Cleveland Clinic Lerner College of Medicine, and a pediatric hospitalist at Cleveland Clinic Children’s. She also serves as the pediatric editor of the Hospitalist, SHM’s monthly news magazine.
• Maylyn S. Martinez, MD, a clinician-researcher and clinical associate at the University of Chicago. Her research focuses on hospital-associated disability and she recently authored a perspectives piece in the Journal of Hospital Medicine with her mentor, Vineet Arora, MD, MHM, on why the COVID-19 pandemic might exacerbate this problem.
• Ndidi Unaka, MD, MEd, an associate professor in the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. Dr. Unaka has served as the associate program director of the pediatric residency program since 2011. She is also the medical director of an inpatient unit that serves as the primary home.

For more information about SHM, please visit hospitalmedicine.org. To learn more about Explore the Space, please visit explorethespaceshow.com.

Register now.




 

Since the advent of COVID-19, health care has seen an unprecedented rise in virtual health. Telemedicine has come to the forefront of our conversations, and there are many speculations around its future state. One such discussion is around the sustainability and expansion of inpatient telemedicine programs post COVID, and if – and how – it is going to be helpful for health care.

Consider the following scenarios:

Scenario 1

A patient presents to an emergency department of a small community hospital. He needs to be seen by a specialist, but (s)he is not available, so patient gets transferred out to the ED of a different hospital several miles away from his hometown.

He is evaluated in the second ED by the specialist, has repeat testing done – some of those tests were already completed at the first hospital. After evaluating him, the specialist recommends that he does not need to be admitted to the hospital and can be safely followed up as an outpatient. The patient does not require any further intervention and is discharged from the ED.
 

Scenario 2

Dr. N is a hospitalist in a rural hospital that does not have intensivist support at night. She works 7 on/7 off and is on call 24/7 during her “on” week. Dr. N cannot be physically present in the hospital 24/7. She receives messages from the hospital around the clock and feels that this call schedule is no longer sustainable. She doesn’t feel comfortable admitting patients in the ICU who come to the hospital at night without physically seeing them and without ICU backup. Therefore, some of the patients who are sick enough to be admitted in ICU for closer monitoring but can be potentially handled in this rural hospital get transferred out to a different hospital.

Dr. N has been asking the hospital to provide her intensivist back up at night and to give her some flexibility in the call schedule. However, from hospital’s perspective, the volume isn’t high enough to hire a dedicated nocturnist, and because the hospital is in the small rural area, it is having a hard time attracting more intensivists. After multiple conversations between both parties, Dr. N finally resigns.
 

Scenario 3

Dr. A is a specialist who is on call covering different hospitals and seeing patients in clinic. His call is getting busier. He has received many new consults and also has to follow up on his other patients in hospital who he saw a day prior.

Dr. A started receiving many pages from the hospitals – some of his patients and their families are anxiously waiting on him so that he can let them go home once he sees them, while some are waiting to know what the next steps and plan of action are. He ends up canceling some of his clinic patients who had scheduled an appointment with him 3, 4, or even 5 months ago. It’s already afternoon.

Dr. A now drives to one hospital, sees his new consults, orders tests which may or may not get results the same day, follows up on other patients, reviews their test results, modifies treatment plans for some while clearing other patients for discharge. He then drives to the other hospital and follows the same process. Some of the patients aren’t happy because of the long wait, a few couldn’t arrange for the ride to go home and ended up staying in hospital 1 extra night, while the ER is getting backlogged waiting on discharges.

These scenarios highlight some of the important and prevalent pain points in health care as shown in Figure 1.

Dr. Zia is an internal medicine board-certified physician, serving as a hospitalist and physician adviser in a medically underserved area. She has also served as interim medical director of the department of hospital medicine, and medical staff president, at SIH Herrin Hospital, in Herrin, Ill., part of Southern Illinois Healthcare. She has a special interest in improving access to health care in physician shortage areas.

References

1. Kindermann DR et al. Emergency department transfers and transfer relationships in United States hospitals. Acad Emerg Med. 2015 Feb;22(2):157-65.

2. Sanders RB et al. New hospital telemedicine services: Potential market for a nighttime hospitalist service. Telemed J E Health. 2014 Oct 1;20(10):902-8.

3. Shanafelt T et al. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-32.

4. Pines JM et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007 Nov;50(5):510-6.

5. Pines JM and Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008 Jan;51(1):1-5.

6. Chalfin DB et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007 Jun;35(6):1477-83.

7. Pines JM et al. The financial consequences of lost demand and reducing boarding in hospital emergency departments. Ann Emerg Med. 2011 Oct;58(4):331-40.

8. Natafgi N et al. Using tele-emergency to avoid patient transfers in rural emergency. J Telemed Telecare. 2018 Apri;24(3):193-201.

9. Providence.org/telehealthhospitalistcasestudy.

10. Woodruff Health Sciences Center. CMS report: eICU program reduced hospital stays, saved millions, eased provider shortage. 2017 Apr 5.

11. Lilly CM et al. ICU telemedicine program financial outcomes. Chest. 2017 Feb;151(2):286-97.

Since the advent of COVID-19, health care has seen an unprecedented rise in virtual health. Telemedicine has come to the forefront of our conversations, and there are many speculations around its future state. One such discussion is around the sustainability and expansion of inpatient telemedicine programs post COVID, and if – and how – it is going to be helpful for health care.

Consider the following scenarios:

Scenario 1

A patient presents to an emergency department of a small community hospital. He needs to be seen by a specialist, but (s)he is not available, so patient gets transferred out to the ED of a different hospital several miles away from his hometown.

He is evaluated in the second ED by the specialist, has repeat testing done – some of those tests were already completed at the first hospital. After evaluating him, the specialist recommends that he does not need to be admitted to the hospital and can be safely followed up as an outpatient. The patient does not require any further intervention and is discharged from the ED.
 

Scenario 2

Dr. N is a hospitalist in a rural hospital that does not have intensivist support at night. She works 7 on/7 off and is on call 24/7 during her “on” week. Dr. N cannot be physically present in the hospital 24/7. She receives messages from the hospital around the clock and feels that this call schedule is no longer sustainable. She doesn’t feel comfortable admitting patients in the ICU who come to the hospital at night without physically seeing them and without ICU backup. Therefore, some of the patients who are sick enough to be admitted in ICU for closer monitoring but can be potentially handled in this rural hospital get transferred out to a different hospital.

Dr. N has been asking the hospital to provide her intensivist back up at night and to give her some flexibility in the call schedule. However, from hospital’s perspective, the volume isn’t high enough to hire a dedicated nocturnist, and because the hospital is in the small rural area, it is having a hard time attracting more intensivists. After multiple conversations between both parties, Dr. N finally resigns.
 

Scenario 3

Dr. A is a specialist who is on call covering different hospitals and seeing patients in clinic. His call is getting busier. He has received many new consults and also has to follow up on his other patients in hospital who he saw a day prior.

Dr. A started receiving many pages from the hospitals – some of his patients and their families are anxiously waiting on him so that he can let them go home once he sees them, while some are waiting to know what the next steps and plan of action are. He ends up canceling some of his clinic patients who had scheduled an appointment with him 3, 4, or even 5 months ago. It’s already afternoon.

Dr. A now drives to one hospital, sees his new consults, orders tests which may or may not get results the same day, follows up on other patients, reviews their test results, modifies treatment plans for some while clearing other patients for discharge. He then drives to the other hospital and follows the same process. Some of the patients aren’t happy because of the long wait, a few couldn’t arrange for the ride to go home and ended up staying in hospital 1 extra night, while the ER is getting backlogged waiting on discharges.

These scenarios highlight some of the important and prevalent pain points in health care as shown in Figure 1.

Dr. Zia is an internal medicine board-certified physician, serving as a hospitalist and physician adviser in a medically underserved area. She has also served as interim medical director of the department of hospital medicine, and medical staff president, at SIH Herrin Hospital, in Herrin, Ill., part of Southern Illinois Healthcare. She has a special interest in improving access to health care in physician shortage areas.

References

1. Kindermann DR et al. Emergency department transfers and transfer relationships in United States hospitals. Acad Emerg Med. 2015 Feb;22(2):157-65.

2. Sanders RB et al. New hospital telemedicine services: Potential market for a nighttime hospitalist service. Telemed J E Health. 2014 Oct 1;20(10):902-8.

3. Shanafelt T et al. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-32.

4. Pines JM et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007 Nov;50(5):510-6.

5. Pines JM and Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008 Jan;51(1):1-5.

6. Chalfin DB et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007 Jun;35(6):1477-83.

7. Pines JM et al. The financial consequences of lost demand and reducing boarding in hospital emergency departments. Ann Emerg Med. 2011 Oct;58(4):331-40.

8. Natafgi N et al. Using tele-emergency to avoid patient transfers in rural emergency. J Telemed Telecare. 2018 Apri;24(3):193-201.

9. Providence.org/telehealthhospitalistcasestudy.

10. Woodruff Health Sciences Center. CMS report: eICU program reduced hospital stays, saved millions, eased provider shortage. 2017 Apr 5.

11. Lilly CM et al. ICU telemedicine program financial outcomes. Chest. 2017 Feb;151(2):286-97.

Since the advent of COVID-19, health care has seen an unprecedented rise in virtual health. Telemedicine has come to the forefront of our conversations, and there are many speculations around its future state. One such discussion is around the sustainability and expansion of inpatient telemedicine programs post COVID, and if – and how – it is going to be helpful for health care.

Consider the following scenarios:

Scenario 1

A patient presents to an emergency department of a small community hospital. He needs to be seen by a specialist, but (s)he is not available, so patient gets transferred out to the ED of a different hospital several miles away from his hometown.

He is evaluated in the second ED by the specialist, has repeat testing done – some of those tests were already completed at the first hospital. After evaluating him, the specialist recommends that he does not need to be admitted to the hospital and can be safely followed up as an outpatient. The patient does not require any further intervention and is discharged from the ED.
 

Scenario 2

Dr. N is a hospitalist in a rural hospital that does not have intensivist support at night. She works 7 on/7 off and is on call 24/7 during her “on” week. Dr. N cannot be physically present in the hospital 24/7. She receives messages from the hospital around the clock and feels that this call schedule is no longer sustainable. She doesn’t feel comfortable admitting patients in the ICU who come to the hospital at night without physically seeing them and without ICU backup. Therefore, some of the patients who are sick enough to be admitted in ICU for closer monitoring but can be potentially handled in this rural hospital get transferred out to a different hospital.

Dr. N has been asking the hospital to provide her intensivist back up at night and to give her some flexibility in the call schedule. However, from hospital’s perspective, the volume isn’t high enough to hire a dedicated nocturnist, and because the hospital is in the small rural area, it is having a hard time attracting more intensivists. After multiple conversations between both parties, Dr. N finally resigns.
 

Scenario 3

Dr. A is a specialist who is on call covering different hospitals and seeing patients in clinic. His call is getting busier. He has received many new consults and also has to follow up on his other patients in hospital who he saw a day prior.

Dr. A started receiving many pages from the hospitals – some of his patients and their families are anxiously waiting on him so that he can let them go home once he sees them, while some are waiting to know what the next steps and plan of action are. He ends up canceling some of his clinic patients who had scheduled an appointment with him 3, 4, or even 5 months ago. It’s already afternoon.

Dr. A now drives to one hospital, sees his new consults, orders tests which may or may not get results the same day, follows up on other patients, reviews their test results, modifies treatment plans for some while clearing other patients for discharge. He then drives to the other hospital and follows the same process. Some of the patients aren’t happy because of the long wait, a few couldn’t arrange for the ride to go home and ended up staying in hospital 1 extra night, while the ER is getting backlogged waiting on discharges.

These scenarios highlight some of the important and prevalent pain points in health care as shown in Figure 1.

Dr. Zia is an internal medicine board-certified physician, serving as a hospitalist and physician adviser in a medically underserved area. She has also served as interim medical director of the department of hospital medicine, and medical staff president, at SIH Herrin Hospital, in Herrin, Ill., part of Southern Illinois Healthcare. She has a special interest in improving access to health care in physician shortage areas.

References

1. Kindermann DR et al. Emergency department transfers and transfer relationships in United States hospitals. Acad Emerg Med. 2015 Feb;22(2):157-65.

2. Sanders RB et al. New hospital telemedicine services: Potential market for a nighttime hospitalist service. Telemed J E Health. 2014 Oct 1;20(10):902-8.

3. Shanafelt T et al. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826-32.

4. Pines JM et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007 Nov;50(5):510-6.

5. Pines JM and Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008 Jan;51(1):1-5.

6. Chalfin DB et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007 Jun;35(6):1477-83.

7. Pines JM et al. The financial consequences of lost demand and reducing boarding in hospital emergency departments. Ann Emerg Med. 2011 Oct;58(4):331-40.

8. Natafgi N et al. Using tele-emergency to avoid patient transfers in rural emergency. J Telemed Telecare. 2018 Apri;24(3):193-201.

9. Providence.org/telehealthhospitalistcasestudy.

10. Woodruff Health Sciences Center. CMS report: eICU program reduced hospital stays, saved millions, eased provider shortage. 2017 Apr 5.

11. Lilly CM et al. ICU telemedicine program financial outcomes. Chest. 2017 Feb;151(2):286-97.

To the Editor:

Unilateral nevoid telangiectasia (UNT) is a rare cutaneous disease characterized by superficial telangiectases arranged in a unilateral linear pattern. First described by Alfred Blaschko in 1899, this rare disease has been reported in higher frequency in recent years, with approximately 100 cases published in the literature according to a PubMed search of articles indexed for MEDLINE using the term unilateral nevoid telangiectasia.¹ Unilateral nevoid telangiectasia can be congenital or acquired; occurs more commonly in women; and typically involves the dermatomal distributions of the trigeminal, cervical, and upper thoracic nerves. Although the pathogenesis of the disease remains unknown, the currently proposed etiology involves hyperestrogenic states, including puberty, pregnancy, and chronic liver disease.² We report a case of progressively worsening, pruritic, unilateral telangiectases of unknown etiology.

A 55-year-old woman presented to our dermatology clinic with progressive red spots involving the right side of the upper body of 3 years’ duration. She noted pruritus, and the rash was otherwise asymptomatic. Her medical history was notable for hypertension, dyspepsia, sciatica, uterine fibroids, and a hysterectomy. Her medications included lisinopril, hydrochlorothiazide, tramadol, aspirin, and a multivitamin. The patient did not report the use of oral contraceptive pills or hormone replacement therapy. She also denied the use of cigarettes or illicit drugs but reported occasional alcohol consumption. A review of systems was negative for any constitutional symptoms or symptoms of liver disease. Her family history also was noncontributory.

Physical examination revealed multiple, 1- to 3-mm, telangiectatic macules and patches in a blaschkoid distribution on the right side of the upper chest, back, shoulder, and arm (Figure, A–C). Darier sign was negative. There was no evidence of palmar erythema, hepatosplenomegaly, ascites, thyromegaly, or thyroid nodules. Dermoscopy confirmed the presence of telangiectasia (Figure, D). More specifically, dermoscopy revealed plump telangiectasia with faint pigment in the background, consistent with UNT. Additionally, there was no pink-white, shiny, scarlike background, and vessels were not thin or arborized, further supporting our diagnosis vs other entities included in the differential diagnosis.

Our case provides another unique presentation of UNT. Our patient was a healthy adult woman with no hyperestrogen-based etiology for disease. Importantly, our patient also represented a rare instance of UNT presenting with symptoms such as pruritus, though UNT classically is described as an asymptomatic phenomenon. In our patient, treatment with PDL was suggested and believed to be warranted not only for cosmetic improvement but also in light of the fact that her lesions were symptomatic.

To the Editor:

Unilateral nevoid telangiectasia (UNT) is a rare cutaneous disease characterized by superficial telangiectases arranged in a unilateral linear pattern. First described by Alfred Blaschko in 1899, this rare disease has been reported in higher frequency in recent years, with approximately 100 cases published in the literature according to a PubMed search of articles indexed for MEDLINE using the term unilateral nevoid telangiectasia.¹ Unilateral nevoid telangiectasia can be congenital or acquired; occurs more commonly in women; and typically involves the dermatomal distributions of the trigeminal, cervical, and upper thoracic nerves. Although the pathogenesis of the disease remains unknown, the currently proposed etiology involves hyperestrogenic states, including puberty, pregnancy, and chronic liver disease.² We report a case of progressively worsening, pruritic, unilateral telangiectases of unknown etiology.

A 55-year-old woman presented to our dermatology clinic with progressive red spots involving the right side of the upper body of 3 years’ duration. She noted pruritus, and the rash was otherwise asymptomatic. Her medical history was notable for hypertension, dyspepsia, sciatica, uterine fibroids, and a hysterectomy. Her medications included lisinopril, hydrochlorothiazide, tramadol, aspirin, and a multivitamin. The patient did not report the use of oral contraceptive pills or hormone replacement therapy. She also denied the use of cigarettes or illicit drugs but reported occasional alcohol consumption. A review of systems was negative for any constitutional symptoms or symptoms of liver disease. Her family history also was noncontributory.

Physical examination revealed multiple, 1- to 3-mm, telangiectatic macules and patches in a blaschkoid distribution on the right side of the upper chest, back, shoulder, and arm (Figure, A–C). Darier sign was negative. There was no evidence of palmar erythema, hepatosplenomegaly, ascites, thyromegaly, or thyroid nodules. Dermoscopy confirmed the presence of telangiectasia (Figure, D). More specifically, dermoscopy revealed plump telangiectasia with faint pigment in the background, consistent with UNT. Additionally, there was no pink-white, shiny, scarlike background, and vessels were not thin or arborized, further supporting our diagnosis vs other entities included in the differential diagnosis.

Our case provides another unique presentation of UNT. Our patient was a healthy adult woman with no hyperestrogen-based etiology for disease. Importantly, our patient also represented a rare instance of UNT presenting with symptoms such as pruritus, though UNT classically is described as an asymptomatic phenomenon. In our patient, treatment with PDL was suggested and believed to be warranted not only for cosmetic improvement but also in light of the fact that her lesions were symptomatic.

To the Editor:

Unilateral nevoid telangiectasia (UNT) is a rare cutaneous disease characterized by superficial telangiectases arranged in a unilateral linear pattern. First described by Alfred Blaschko in 1899, this rare disease has been reported in higher frequency in recent years, with approximately 100 cases published in the literature according to a PubMed search of articles indexed for MEDLINE using the term unilateral nevoid telangiectasia.¹ Unilateral nevoid telangiectasia can be congenital or acquired; occurs more commonly in women; and typically involves the dermatomal distributions of the trigeminal, cervical, and upper thoracic nerves. Although the pathogenesis of the disease remains unknown, the currently proposed etiology involves hyperestrogenic states, including puberty, pregnancy, and chronic liver disease.² We report a case of progressively worsening, pruritic, unilateral telangiectases of unknown etiology.

A 55-year-old woman presented to our dermatology clinic with progressive red spots involving the right side of the upper body of 3 years’ duration. She noted pruritus, and the rash was otherwise asymptomatic. Her medical history was notable for hypertension, dyspepsia, sciatica, uterine fibroids, and a hysterectomy. Her medications included lisinopril, hydrochlorothiazide, tramadol, aspirin, and a multivitamin. The patient did not report the use of oral contraceptive pills or hormone replacement therapy. She also denied the use of cigarettes or illicit drugs but reported occasional alcohol consumption. A review of systems was negative for any constitutional symptoms or symptoms of liver disease. Her family history also was noncontributory.

Physical examination revealed multiple, 1- to 3-mm, telangiectatic macules and patches in a blaschkoid distribution on the right side of the upper chest, back, shoulder, and arm (Figure, A–C). Darier sign was negative. There was no evidence of palmar erythema, hepatosplenomegaly, ascites, thyromegaly, or thyroid nodules. Dermoscopy confirmed the presence of telangiectasia (Figure, D). More specifically, dermoscopy revealed plump telangiectasia with faint pigment in the background, consistent with UNT. Additionally, there was no pink-white, shiny, scarlike background, and vessels were not thin or arborized, further supporting our diagnosis vs other entities included in the differential diagnosis.

Our case provides another unique presentation of UNT. Our patient was a healthy adult woman with no hyperestrogen-based etiology for disease. Importantly, our patient also represented a rare instance of UNT presenting with symptoms such as pruritus, though UNT classically is described as an asymptomatic phenomenon. In our patient, treatment with PDL was suggested and believed to be warranted not only for cosmetic improvement but also in light of the fact that her lesions were symptomatic.

In his role as head of the division of pediatric behavioral health at National Jewish Health, Denver, Bruce G. Bender, PhD, helps children and adults navigate the adverse effects of severe atopic dermatitis (AD) on their quality of life.

“There have been many surveys of adults with AD who report impairment of their sleep, reduced activity level, increased work absence, financial burden, emotional distress, and social avoidance,” he said at the Revolutionizing Atopic Dermatitis virtual symposium. “Similarly, children with AD or their parents report emotional distress, reduced activity, and increased school absence, social avoidance, and sleep disturbance. Families report financial burdens, conflict, particularly among the adults, social avoidance, sleep disturbance in the parents, and reduction of well-being in the siblings.”

Getting adequate sleep is especially challenging for patients with AD, and loss of sleep can have serious daytime consequences. In an effort to objectively measure sleep change in this population, Dr. Bender and colleagues recruited 14 adults with AD and 14 healthy controls who wore an ActiGraph for 1 week and completed questionnaires about sleep, itch, and quality of life. Patients with AD were awake almost twice as many minutes each night as the healthy controls (a mean of 57.3 vs. 32.3 minutes, respectively; P = .0480). Consequently, their sleep efficiency was significantly reduced based on the Pittsburgh sleep quality index (a mean of 90.6 vs. 95; P = .0305).

In another study, Dr. Bender and colleagues enrolled 20 adults with AD who underwent 2 nights of polysomnography and actigraphy. The lab was set up to measure a scratching event, which was recorded when a burst of electromyographic activity of at least 3 seconds was accompanied by a visible scratching motion. “We learned that sleep efficiency as measured by both PSG and actigraphy correlated with total body surface area and scratching index,” he said. “As we might assume, the more skin involved, the more patients scratch, the less well they sleep.”
 

Behavioral, neurocognitive effects

In a separate study of AD, sleep, and behavior, the researchers studied 1,041 children with asthma who were enrolled in the Childhood Asthma Management Program at eight North American sites. They used baseline parent ratings on standardized sleep and behavior rating scales and found that increased awakenings were associated with increased school absence and daytime behavior problems. “So, not only do children with AD sleep less well, but this shows up to impair their functioning during the day,” said Dr. Bender, professor of psychiatry at the University of Colorado, Denver.

In a report from Australia, researchers set out to explore the association between sleep and neurocognitive function in 21 children with eczema and 20 healthy controls. Participants underwent cognitive testing and polysomnography. The authors found that the children with eczema demonstrated lower test scores. Reduced scores were correlated with parental reports of sleep problems but not polysomnography.

In a much larger study funded by the Agency for Healthcare Research and Quality, investigators analyzed data on 354,416 children and 34,613 adults from 19 U.S. population surveys including the National Health Interview Survey 1997-2013 and the National Survey of Children’s Health 2003/4 and 2007/8. They found that AD was associated with ADHD in children (adjusted odds ratio, 1.14) and adults (aOR, 1.61). Higher odds of ADHD were found in children who had significant sleep disturbance (aOR, 16.83) and other allergic disease and asthma (aOR, 1.61).

“All of these findings show that AD can impact quality of life, especially sleep, with the result of poorer daytime functioning,” Dr. Bender said. “But those studies don’t answer this question: Are patients with AD at increased risk for psychological disorders such as depression and anxiety?”
 

Impact on depression, anxiety

Two systematic reviews on the topic suggest that patients with AD are twice as likely to experience depression. One was published in 2018 and the other in 2019. The 2018 review reported a little more than a twofold increase (OR, 2.19), the 2019 review a little bit less (OR, 1.71).

“At the more severe end of the depression continuum, we sometimes see suicidal ideation and suicide attempts,” Dr. Bender said. “A number of studies have asked whether these are increased in patients with AD. Quite a few studies collectively show an increased incidence of suicidal ideation. The question of suicide attempts is reflected in fewer studies. And while the result is small, it is significant. There is a significant increase reported of suicide attempts in AD patients.”

The 2018 review also found an increased incidence of anxiety in AD patients: a little more than twofold in adults (OR, 2.19) and a little less than twofold in children (OR, 1.81).

“It’s a two-way relationship between AD and psychological factors,” Dr. Bender said. “We generally think about AD – the stress that it brings, the burden that it puts on children, adults, and families. But it can work the other way around,” he said, referring to patients who have psychological problems, experience a great deal of stress, have trouble being adherent to their treatment regimen, and find it difficult to resist scratching. “The behavioral/psychological characteristics of the patient also drive the AD. It is well established that acute and chronic stress can result in a worsening of skin conditions in AD patients.”

Behavioral health interventions that have been described in the literature include cognitive therapy, stress management, biofeedback, hypnotherapy, relaxation training, mindfulness, habit reversal, and patient education – some of which have been tested in randomized trials. “All of them report a decrease in scratching as a consequence of the behavioral intervention,” Dr. Bender said.

“Other studies have been reported that look at the impact of behavioral interventions on the severity of the skin condition. Most report an improvement in the skin condition from these behavioral interventions but it’s not a perfect literature.” Critiques of these studies include the fact that there is often not enough detail about the intervention or the framework for the intervention that would allow a clinician to test an intervention in another study or actually pull that intervention into clinical practice (Cochrane Database Syst Rev. 2014 Jan 7;2014[1]:CD004054), (Int Arch Allergy Immunol.2007;144[1]:1-9).

“Some of the studies lack rigorous designs, some have sampling bias, and some have inadequate outcome measurements,” he said. “We really need additional, high-quality studies to look at what is helpful for patients with AD.”

Dr. Bender reported having no financial disclosures.

dbrunk@mdedge.com

In his role as head of the division of pediatric behavioral health at National Jewish Health, Denver, Bruce G. Bender, PhD, helps children and adults navigate the adverse effects of severe atopic dermatitis (AD) on their quality of life.

“There have been many surveys of adults with AD who report impairment of their sleep, reduced activity level, increased work absence, financial burden, emotional distress, and social avoidance,” he said at the Revolutionizing Atopic Dermatitis virtual symposium. “Similarly, children with AD or their parents report emotional distress, reduced activity, and increased school absence, social avoidance, and sleep disturbance. Families report financial burdens, conflict, particularly among the adults, social avoidance, sleep disturbance in the parents, and reduction of well-being in the siblings.”

Getting adequate sleep is especially challenging for patients with AD, and loss of sleep can have serious daytime consequences. In an effort to objectively measure sleep change in this population, Dr. Bender and colleagues recruited 14 adults with AD and 14 healthy controls who wore an ActiGraph for 1 week and completed questionnaires about sleep, itch, and quality of life. Patients with AD were awake almost twice as many minutes each night as the healthy controls (a mean of 57.3 vs. 32.3 minutes, respectively; P = .0480). Consequently, their sleep efficiency was significantly reduced based on the Pittsburgh sleep quality index (a mean of 90.6 vs. 95; P = .0305).

In another study, Dr. Bender and colleagues enrolled 20 adults with AD who underwent 2 nights of polysomnography and actigraphy. The lab was set up to measure a scratching event, which was recorded when a burst of electromyographic activity of at least 3 seconds was accompanied by a visible scratching motion. “We learned that sleep efficiency as measured by both PSG and actigraphy correlated with total body surface area and scratching index,” he said. “As we might assume, the more skin involved, the more patients scratch, the less well they sleep.”
 

Behavioral, neurocognitive effects

In a separate study of AD, sleep, and behavior, the researchers studied 1,041 children with asthma who were enrolled in the Childhood Asthma Management Program at eight North American sites. They used baseline parent ratings on standardized sleep and behavior rating scales and found that increased awakenings were associated with increased school absence and daytime behavior problems. “So, not only do children with AD sleep less well, but this shows up to impair their functioning during the day,” said Dr. Bender, professor of psychiatry at the University of Colorado, Denver.

In a report from Australia, researchers set out to explore the association between sleep and neurocognitive function in 21 children with eczema and 20 healthy controls. Participants underwent cognitive testing and polysomnography. The authors found that the children with eczema demonstrated lower test scores. Reduced scores were correlated with parental reports of sleep problems but not polysomnography.

In a much larger study funded by the Agency for Healthcare Research and Quality, investigators analyzed data on 354,416 children and 34,613 adults from 19 U.S. population surveys including the National Health Interview Survey 1997-2013 and the National Survey of Children’s Health 2003/4 and 2007/8. They found that AD was associated with ADHD in children (adjusted odds ratio, 1.14) and adults (aOR, 1.61). Higher odds of ADHD were found in children who had significant sleep disturbance (aOR, 16.83) and other allergic disease and asthma (aOR, 1.61).

“All of these findings show that AD can impact quality of life, especially sleep, with the result of poorer daytime functioning,” Dr. Bender said. “But those studies don’t answer this question: Are patients with AD at increased risk for psychological disorders such as depression and anxiety?”
 

Impact on depression, anxiety

Two systematic reviews on the topic suggest that patients with AD are twice as likely to experience depression. One was published in 2018 and the other in 2019. The 2018 review reported a little more than a twofold increase (OR, 2.19), the 2019 review a little bit less (OR, 1.71).

“At the more severe end of the depression continuum, we sometimes see suicidal ideation and suicide attempts,” Dr. Bender said. “A number of studies have asked whether these are increased in patients with AD. Quite a few studies collectively show an increased incidence of suicidal ideation. The question of suicide attempts is reflected in fewer studies. And while the result is small, it is significant. There is a significant increase reported of suicide attempts in AD patients.”

The 2018 review also found an increased incidence of anxiety in AD patients: a little more than twofold in adults (OR, 2.19) and a little less than twofold in children (OR, 1.81).

“It’s a two-way relationship between AD and psychological factors,” Dr. Bender said. “We generally think about AD – the stress that it brings, the burden that it puts on children, adults, and families. But it can work the other way around,” he said, referring to patients who have psychological problems, experience a great deal of stress, have trouble being adherent to their treatment regimen, and find it difficult to resist scratching. “The behavioral/psychological characteristics of the patient also drive the AD. It is well established that acute and chronic stress can result in a worsening of skin conditions in AD patients.”

Behavioral health interventions that have been described in the literature include cognitive therapy, stress management, biofeedback, hypnotherapy, relaxation training, mindfulness, habit reversal, and patient education – some of which have been tested in randomized trials. “All of them report a decrease in scratching as a consequence of the behavioral intervention,” Dr. Bender said.

“Other studies have been reported that look at the impact of behavioral interventions on the severity of the skin condition. Most report an improvement in the skin condition from these behavioral interventions but it’s not a perfect literature.” Critiques of these studies include the fact that there is often not enough detail about the intervention or the framework for the intervention that would allow a clinician to test an intervention in another study or actually pull that intervention into clinical practice (Cochrane Database Syst Rev. 2014 Jan 7;2014[1]:CD004054), (Int Arch Allergy Immunol.2007;144[1]:1-9).

“Some of the studies lack rigorous designs, some have sampling bias, and some have inadequate outcome measurements,” he said. “We really need additional, high-quality studies to look at what is helpful for patients with AD.”

Dr. Bender reported having no financial disclosures.

dbrunk@mdedge.com

In his role as head of the division of pediatric behavioral health at National Jewish Health, Denver, Bruce G. Bender, PhD, helps children and adults navigate the adverse effects of severe atopic dermatitis (AD) on their quality of life.

“There have been many surveys of adults with AD who report impairment of their sleep, reduced activity level, increased work absence, financial burden, emotional distress, and social avoidance,” he said at the Revolutionizing Atopic Dermatitis virtual symposium. “Similarly, children with AD or their parents report emotional distress, reduced activity, and increased school absence, social avoidance, and sleep disturbance. Families report financial burdens, conflict, particularly among the adults, social avoidance, sleep disturbance in the parents, and reduction of well-being in the siblings.”

Getting adequate sleep is especially challenging for patients with AD, and loss of sleep can have serious daytime consequences. In an effort to objectively measure sleep change in this population, Dr. Bender and colleagues recruited 14 adults with AD and 14 healthy controls who wore an ActiGraph for 1 week and completed questionnaires about sleep, itch, and quality of life. Patients with AD were awake almost twice as many minutes each night as the healthy controls (a mean of 57.3 vs. 32.3 minutes, respectively; P = .0480). Consequently, their sleep efficiency was significantly reduced based on the Pittsburgh sleep quality index (a mean of 90.6 vs. 95; P = .0305).

In another study, Dr. Bender and colleagues enrolled 20 adults with AD who underwent 2 nights of polysomnography and actigraphy. The lab was set up to measure a scratching event, which was recorded when a burst of electromyographic activity of at least 3 seconds was accompanied by a visible scratching motion. “We learned that sleep efficiency as measured by both PSG and actigraphy correlated with total body surface area and scratching index,” he said. “As we might assume, the more skin involved, the more patients scratch, the less well they sleep.”
 

Behavioral, neurocognitive effects

In a separate study of AD, sleep, and behavior, the researchers studied 1,041 children with asthma who were enrolled in the Childhood Asthma Management Program at eight North American sites. They used baseline parent ratings on standardized sleep and behavior rating scales and found that increased awakenings were associated with increased school absence and daytime behavior problems. “So, not only do children with AD sleep less well, but this shows up to impair their functioning during the day,” said Dr. Bender, professor of psychiatry at the University of Colorado, Denver.

In a report from Australia, researchers set out to explore the association between sleep and neurocognitive function in 21 children with eczema and 20 healthy controls. Participants underwent cognitive testing and polysomnography. The authors found that the children with eczema demonstrated lower test scores. Reduced scores were correlated with parental reports of sleep problems but not polysomnography.

In a much larger study funded by the Agency for Healthcare Research and Quality, investigators analyzed data on 354,416 children and 34,613 adults from 19 U.S. population surveys including the National Health Interview Survey 1997-2013 and the National Survey of Children’s Health 2003/4 and 2007/8. They found that AD was associated with ADHD in children (adjusted odds ratio, 1.14) and adults (aOR, 1.61). Higher odds of ADHD were found in children who had significant sleep disturbance (aOR, 16.83) and other allergic disease and asthma (aOR, 1.61).

“All of these findings show that AD can impact quality of life, especially sleep, with the result of poorer daytime functioning,” Dr. Bender said. “But those studies don’t answer this question: Are patients with AD at increased risk for psychological disorders such as depression and anxiety?”
 

Impact on depression, anxiety

Two systematic reviews on the topic suggest that patients with AD are twice as likely to experience depression. One was published in 2018 and the other in 2019. The 2018 review reported a little more than a twofold increase (OR, 2.19), the 2019 review a little bit less (OR, 1.71).

“At the more severe end of the depression continuum, we sometimes see suicidal ideation and suicide attempts,” Dr. Bender said. “A number of studies have asked whether these are increased in patients with AD. Quite a few studies collectively show an increased incidence of suicidal ideation. The question of suicide attempts is reflected in fewer studies. And while the result is small, it is significant. There is a significant increase reported of suicide attempts in AD patients.”

The 2018 review also found an increased incidence of anxiety in AD patients: a little more than twofold in adults (OR, 2.19) and a little less than twofold in children (OR, 1.81).

“It’s a two-way relationship between AD and psychological factors,” Dr. Bender said. “We generally think about AD – the stress that it brings, the burden that it puts on children, adults, and families. But it can work the other way around,” he said, referring to patients who have psychological problems, experience a great deal of stress, have trouble being adherent to their treatment regimen, and find it difficult to resist scratching. “The behavioral/psychological characteristics of the patient also drive the AD. It is well established that acute and chronic stress can result in a worsening of skin conditions in AD patients.”

Behavioral health interventions that have been described in the literature include cognitive therapy, stress management, biofeedback, hypnotherapy, relaxation training, mindfulness, habit reversal, and patient education – some of which have been tested in randomized trials. “All of them report a decrease in scratching as a consequence of the behavioral intervention,” Dr. Bender said.

“Other studies have been reported that look at the impact of behavioral interventions on the severity of the skin condition. Most report an improvement in the skin condition from these behavioral interventions but it’s not a perfect literature.” Critiques of these studies include the fact that there is often not enough detail about the intervention or the framework for the intervention that would allow a clinician to test an intervention in another study or actually pull that intervention into clinical practice (Cochrane Database Syst Rev. 2014 Jan 7;2014[1]:CD004054), (Int Arch Allergy Immunol.2007;144[1]:1-9).

“Some of the studies lack rigorous designs, some have sampling bias, and some have inadequate outcome measurements,” he said. “We really need additional, high-quality studies to look at what is helpful for patients with AD.”

Dr. Bender reported having no financial disclosures.

dbrunk@mdedge.com