Silver linings emerge for hospitalists
For Elisabeth Souther, MD, chief of hospital medicine at Dartmouth-Hitchcock Medical Center, a rural, academic hospital with almost 400 beds in Lebanon, N.H., the last two years have been challenging beyond belief. “In the spring of 2020, we were dealing with a disease we knew virtually nothing about, we didn’t know if personal protective equipment (PPE) would protect us, we had no idea if we had enough PPE, we were concerned that members of our own ranks would die from COVID-19, and we didn’t know how long the pandemic would last,” she said. “We did what we do best as doctors—we cared for patients, and we kept going even though every step was hard.”
The tolls and challenges related to the coronavirus have certainly changed over the past two years, Dr. Souther continued. “In the beginning, we were concerned about our own personal safety and the fear of what we didn’t know,” she said. “Now, we worry about compassion fatigue in our hospitalists, given the politicization of COVID-19 vaccines and therapies. It’s hard to be a compassionate, caring doctor when patients insist on alternate therapies or when dying COVID-19 patients’ families refuse to believe that COVID-19 is a real disease.”
Dr. Souther also worries about the long-term effects of burnout. “Our team has tried to maintain the mantra of ‘this is a marathon, not a race,’ but the pandemic is turning into an ultramarathon and many of us are tired,” she said.
Likewise, Daniel J. Brotman, MD, MHM, division director of hospital medicine at Johns Hopkins Hospital in Baltimore, an academic hospital with more than 1,000 beds, said the pandemic is getting old and tiring. “Burnout was already an issue pre-pandemic,” he said. “Now, hospitalists have to deal with additional personal and professional challenges such as: trying to do clinical work while caring for children who lack reliable childcare; social isolation at work and home; added friction in clinical care including the challenges of discharging patients with COVID-19; and having fewer staff members in the hospital to help with care coordination and covering for sick colleagues.”
Additionally, Dr. Brotman said the controversy and polarization around vaccination have led to compassion fatigue and bitterness. “It’s easy to get angry at patients who are overflowing our hospitals and the ill-informed social media forces that brainwashed them,” he said.
Effects on leadership
With the ongoing challenges that resulted from the pandemic, some hospitalists remained capable leaders while others felt a need to step down. Dr. Souther said her leadership team remained strong and intact. “We watched out for each other and worked well as a team,” she said. “If one team member seemed down, another picked up the slack. Regular, honest communication saved us. Our administration has supported us every step of the way and we’ve had a seat at the table to discuss and support COVID-19 policy changes.”
Albert I. Soriano, MD, FACP, director of medical operations for the department of hospital medicine at Sentara Medical Group in Hampton Roads, Va., has seen existing leaders become better leaders. “Hospitalist leaders helped create solutions, assisted in crisis management, and have improved their communication skills,” he said. “We’ve also seen informal leaders step up to help find clinical and process solutions.” Soriano oversees seven of the group’s 12 hospitalist programs, approximately 1,800 beds.
On the flip side, Venkatrao Medarametla, MD, MBA, medical director of hospital medicine at Baystate Health in Springfield, Mass., an academic facility with 750 beds, has seen hospitalist leaders resign or retire early due to the pressures of hospital capacity issues and not having enough staff to manage the increasing census. “A paucity of resources, inadequate empathy toward our struggles, and the relentless pressure to free up capacity from management have affected the morale of many capable and strong leaders, causing them to step down from leadership roles,” he said.
While Tomas Villanueva, DO, MBA, FACPE, SFHM, principal of clinical operations and quality at Irving-Texas based Vizient, Inc., a health care performance-improvement company where he consults with hospitals nationwide, hasn’t seen the “great resignation” among hospital medicine leadership nor faculty within the hospital’s teams. However, he has seen more seasoned hospitalists transition into part-time positions. This has worsened staffing issues and affected operational efficiencies because they’re more dependent on less-experienced physicians.
Ramesh Adhikari, MD, MS, SFHM, a hospitalist and geriatrician in the department of hospital medicine at Franciscan Health in Lafayette, Ind., who works at three rural hospitals with 25 to 200 beds, said that due to a huge surge in hospitalizations during the delta and omicron waves, hospitalist leaders have had to work almost daily to help with staffing shortages. Consequently, he saw leaders work every single day. Given these demands, hospitalist leaders around the country have stepped back from their roles. Some leaders are sharing the responsibility with co-directors to reduce burnout.
At the beginning of the pandemic, protocols on how to treat COVID-19 were limited. Hospitalists collected data on each patient and developed the best possible treatment plans. “Some hospitalists had to perform procedures that they hadn’t done since their residency training,” said Brooke Meadors, director of provider strategy at Vivian Health, a national health care hiring marketplace based in San Francisco. “They had to freshen up their skills or practice outside their scope of practice.”
For Dr. Villanueva, who is also a hospitalist and internal medicine physician at a Florida community hospital with 1,000 beds, a big challenge is treating coronavirus patients with chronic conditions. “Oftentimes, we don’t know if a COVID-19 infection will further complicate a chronic condition and if treating COVID-19 will complicate or contradict a chronic condition’s treatment,” he said.
Hospitalists at Franciscan Health were challenged with caring for complicated patients who, pre-COVID-19, would have been transferred to higher-level centers. This wasn’t possible, however, because other centers were at capacity. To care for these patients, Dr. Adhikari and his colleagues consulted specialty physicians via telemedicine within their health system and other hospitals through transfer centers for phone consults, who advised them on how to make the most of their limited resources.
Constantly changing practice standards and treatment guidelines, as well as insufficient time to keep up with updates, inhibited maintaining a work/life balance, Dr. Medarametla said. He also grappled with testing delays and insurance-coverage issues.
Furthermore, Dr. Medarametla had to follow resource-allocation policies and couldn’t offer lifesaving treatments such as ventilators to certain patients. “Having challenging conversations about the end of life with patients and families due to inadequate resources added stress that I never experienced before,” he said.
The pandemic paused career growth for many hospitalists. With increased stress levels and a focus entirely on clinical management, most hospitalists didn’t have enough time to attend continuing-medical-education events and professional-development courses, said Dr. Medarametla, who is also the president of the Western Massachusetts chapter of SHM. Hospitalists’ attendance at SHM chapter events remained low despite providers making them virtual, allowing non-members, and expanding offerings to residents and advanced practitioners. He also noticed decreased attendance at national meetings.
Kierstin Cates Kennedy, MD, MSHA, FACP, SFHM, interim chief medical officer of hospital medicine at the University of Alabama at Birmingham, an academic hospital with 1,200 beds, said clinical-care demands significantly affected hospitalists’ ability to devote energy to non-clinical activities, such as teaching, research, quality-improvement efforts, and leadership roles. “This can impact job satisfaction, increase risk of burnout, and negatively impact progress toward academic promotion,” she said.
Dr. Medarametla said some hospitalists became sick with the coronavirus and developed post-COVID-19 syndromes of varying severity. “Some don’t have the same energy as before and feel tired, but still have to come to work because the hospital will shut down without hospitalists,” he said.
A lack of outpatient service options
Challenges associated with discharging patients have also plagued hospitalists. Throughput is a major issue nationwide, said Bartho Caponi, MD, FHM, clinical professor of medicine in the department of internal medicine at the University of Wisconsin, an academic facility with 500 beds in Madison, Wis. Due to an insufficient supply of outpatient services and facilities, patients can’t get the care they need in a non-acute setting. Consequently, they occupy hospital beds unnecessarily while others wait to be admitted.
Outpatient venues are lacking due to staffing shortages and some facilities refuse to accept COVID-19 patients until their infections have cleared—forcing them to stay in the hospital longer than might be necessary, Dr. Brotman said.
A lack of outpatient services or patients’ unwillingness to seek outpatient treatment out of fear of being exposed to the virus often results in patients with a dire need for attention flooding emergency rooms, Ms. Meadors said.
Effects on medical students
In addition to the pandemic affecting hospitalists’ careers in a variety of ways, some medical students’ and residents’ career paths were also impacted. “Some medical residents witnessed hospitalists in action as frontline health care heroes, and were inspired to pursue hospital medicine,” Dr. Medarametla said. Conversely, some residents saw how stressful a hospitalists’ job can get and decided against pursuing hospital medicine as a career. Instead, they chose a specialty or primary care.
Ilaria Gadalla, DMSc, PA-C, FHM, a hospital medicine PA with Treasure Coast Hospitalists who practices at community hospitals in Stuart, Fla., said that many hospitalist groups have had difficulty recruiting physician assistants and nurse practitioners into the field of medicine. “Due to COVID-19, the number of students permitted into hospitals for inpatient training and clinical rotations has decreased, and in some cases, they’re completely excluded,” she said. “If students don’t experience inpatient medical care, they can’t be inspired to pursue it.”
In addition to not seeing hospitalists on the job, students had limited exposure to the other ways that hospitalists impact the health care system, such as serving on hospital committees, doing quality and patient safety work, helping to improve systems, and engaging in research and mentorship, said Daniel Ricotta, MD, SFHM, a hospitalist and assistant professor of medicine at Harvard Medical School in Cambridge, Mass., and associate program director of medicine at Beth Israel Deaconess Medical Center in Boston. The urban academic medical center has approximately 650 beds.
Brian Kwan, MD, a hospitalist in the department of medicine at VA San Diego Healthcare System, an academic adult hospital with almost 300 beds, however, doesn’t think COVID-19 has negatively influenced medical residents’ decisions to become hospitalists. “If anything, the pandemic has solidified the importance of hospitalists’ roles in addressing surge planning, disseminating information quickly across national forums and networks to inform the latest practice guidelines, strengthening communities of practice, and developing novel research questions and targets,” he said.
Promoting the profession
Considering some students being deterred from pursuing hospital medicine, hospitalists need to communicate that hospital medicine is synonymous with adaptability and resilience. “During the pandemic, hospitalists have been the primary team members caring for COVID-19 patients,” Dr. Medarametla said. Sometimes they even ventured beyond their capabilities and practiced at the top of their licenses by working in intensive-care units when those teams were overwhelmed.
During the pandemic, most health care systems realized the value of hospitalists. “In the next five years, I think hospitalists will take center stage in health-system operations and leadership and maintain a crucial role in all divisions, such as safety, quality, operations, finances, and patient satisfaction,” Dr. Medarametla said.
Given their minimal exposure, Dr. Ricotta said it’s key for hospitalists to mentor students and have one-on-one conversations explaining what a career is like and what to expect daily.
Dr. Soriano believes that hospitalists will come out of this crisis better than when they started. “In the past, it was almost taboo to talk about burnout and work/life balance,” he said. “Moving forward, we need to be mindful of this and address it proactively. We’re looking at how we can leverage technology to provide innovative staffing solutions. For instance, we are developing a centralized ‘e-hub’ to provide remote solutions to support our providers.”
Dr. Souther also foresees many silver linings emerging from the pandemic. “We’ve learned that with good communication, an open mind, and trust, we can solve just about any problem,” she said. “We’ve made changes to our schedules and workflows repeatedly over the last two years and realize that some changes we previously would never have considered, actually work. We’ve also learned that change is actually not always hard. The pandemic has undoubtedly made us stronger and tougher than ever before.”
Karen Appold is an award-winning journalist based in Lehigh Valley, Pa. She has more than 25 years of editorial experience, including newspaper reporter and newspaper and magazine editor. Reach her at [email protected]