Perspectives

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

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

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

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

The current pandemic is forcing changes throughout the health care industry. Telehealth is witnessing a surge. Hospitals are struggling without elective care, and remarkably, physicians are being laid off during a time of crisis. While some states have a surplus work force, other states go begging, and they lock the system up with delays in the processing of applications.

Considering the prevalence of noncompete clauses and a schism in state-to-state processing of complaints, patients are suffering and dying under an antiquated system. The Federation of State Medical Boards doesn’t seem to add to the solution, but instead confounds the problem with new directives. The time is nigh for the federal government to eliminate state medical licensure and replace it with a national medical license for all physicians and health care professionals.

Because physicians’ training requirements don’t vary from state to state, it makes sense. We must take national standardized exams to qualify. Locum tenens physicians must maintain licensure in as many states as they practice; this creates an unnecessary burden and expense, when there is a better alternative. Some states have arranged reciprocity licensure with other states. This is commendable but doesn’t go far enough to manage national shortages in rural areas.

Under a national licensing system, physicians and other health care professionals would not only be free to travel anywhere in the United States to practice, they can count on consistent and equal management of their license. The federal government can track regional overages and shortages and redirect physicians and other medical professionals with incentives to areas in need.

The FSMB claims that there is interstate continuity among state medical boards, but the data don’t support this.

Why is this the case? Each medical board fails to manage their charges equally. Often, action taken by one state board when reported to another state board can cause a review and readjudication. This occasionally results in the overturning of a reprimand or suspension because of differences in legislation.

Yet the physician or health care professional must bear the burden of the notification against their license. Once again, the FSMB claims there is interstate continuity in disciplinary actions, but the data do not support this.

Once someone brings a complaint against a health professional, which in this health care climate is inevitable, the medical board must institute an investigation. Even if it has no merit, the process must go forward. Under a national system, a consistent approach to dismiss and investigate issues and complaints might expedite the process. This eliminates inefficiency and delays in clearance of charges.

A report in 2006 identified fragmentation and discontinuities in the way each state medical board manages a physician or other health care personnel’s complaints. The number of hands involved in the process varies and is often onerous and redundant. Several sources may request the same information, tying it up as it moves through an inefficient and uncooperative system. With the increase in internal politics since then, this only compounds rather than improves the problem.

Yet the benefit of national licensure is not just for the health care personnel but also for insurance companies that must register and screen physicians as they move from region to region. In each state, the physician must repeat the accreditation process, delaying reimbursements and denying care. Hospitals also must repeat the credentialing task as well. This, although the physician or health care worker has a clean record with the same company or the same hospital system in their original state.

Perhaps data from one insurance group or hospital in another state get lost or altered in transfer, but under national licensing, this would not be possible. Furthermore, the current system limits the individual professional’s input. By nationalizing, record corrections would go through a federal database rather than state data banks that don’t sync.

This already partially exists with the National Practitioner Identifier. But we can take it one step further. Through nationalization, we could institute a fairer system of reporting where both the professional’s and the complainant’s summary is included. One might argue the National Physician Data Bank performs this function, but in fact, it merely reflects state assessments – which again vary.

The infrastructure is already in place to transition from a state to national system with facilities and records kept in each state’s medical board. It would simply be a matter of replacing state personnel with federal employees who all work from the same script. A national medical license simply makes sense for all parties. It reduces discontinuity and increases efficiency. A national medical license empowers the individual rather than institutions, yet benefits both.

The time is nigh to nationally certify and set physicians free, reduce paperwork and needless fees, and eliminate state supremacy.  


Dr. Raymond is an emergency physician based in Hickory, N.C., and Muckendorf an der Donau, Austria.

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

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

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

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

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

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

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

Learning from our health care colleagues

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

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

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

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

From theory to application

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

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

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

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

Process of two podcasts

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

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

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

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

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

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

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

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

Future applications and initiatives

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

Learning from our health care colleagues

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

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

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

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

From theory to application

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

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

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

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

Process of two podcasts

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

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

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

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

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

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

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

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

Future applications and initiatives

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

Learning from our health care colleagues

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

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

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

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

From theory to application

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

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

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

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

Process of two podcasts

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

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

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

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

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

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

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

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

Future applications and initiatives

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

References

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

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

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

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

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

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

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

Mayo Clinic findings on radio communication used by mobile phones

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

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

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

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

Smartphones’ risks to patient with cardiac devices

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

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

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

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

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

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

Mayo Clinic findings on radio communication used by mobile phones

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

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

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

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

Smartphones’ risks to patient with cardiac devices

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

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

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

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

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

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

Mayo Clinic findings on radio communication used by mobile phones

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

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

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

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

Smartphones’ risks to patient with cardiac devices

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Current malpractice environment for hospitalists

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

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

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

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

Making hospital medicine safer

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

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

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

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

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

Applying insights from malpractice claims analysis to clinical practice

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Current malpractice environment for hospitalists

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

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

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

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

Making hospital medicine safer

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

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

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

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

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

Applying insights from malpractice claims analysis to clinical practice

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Current malpractice environment for hospitalists

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

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

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

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

Making hospital medicine safer

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

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

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

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

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

Applying insights from malpractice claims analysis to clinical practice

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Need a new clinical schedule by Sunday? Check.

Need help with new clinical protocols? Check.

Need to help other colleagues? Check.

Need to reprogram the EMR? Check.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Protecting the most vulnerable

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Protecting the most vulnerable

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Protecting the most vulnerable

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

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

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

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

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

Psychiatry and neurology are the brain’s twin medical disciplines. Unlike neurologic brain disorders, where localizing the “lesion” is a primary objective, psychiatric brain disorders are much more subtle, with no “gross” lesions but numerous cellular and molecular pathologies within neural circuits.

Measuring the molecular components of the cerebrospinal fluid (CSF), the glorious “sewage system” of the brain, may help reveal granular clues to the neurobiology of psychiatric disorders.

Mental illnesses involve the disruption of brain structures and functions in a diffuse manner across the cortex. Abnormal neuroplasticity has been implicated in several major psychiatric disorders. Examples include hypoplasia of the hippocampus in major depressive disorder and cortical thinning/dysplasia in schizophrenia. Reductions of neurotropic factors such as nerve growth factor or brain-derived neurotropic factor have been reported in mood and psychotic disorders, and appear to correlate with neuroplasticity changes.

Recent advances in psychiatric neuroscience have provided many clues to the pathophysiology of psychopathological conditions, including neuroinflammation, oxidative stress, apoptosis, impaired energy metabolism, abnormal metabolomics and lipidomics, and hypo- and hyperfunction of various neurotransmitters systems (especially glutamate N-methyl-D-aspartate receptors, dopamine D2 receptors, serotonin 5-HT2A receptors, and gamma-amino­butyric acid receptors). Gray matter neurodegenerative changes as well as myelin disintegration in various psychiatric disorders point to significant neuropil and white matter pathologies across major psychiatric disorders. Dysfunctional glial cells (astroglia, microglia, and oligodendroglia) have also emerged as a central abnormality in psychiatric disorders. Permeability of the blood-brain barrier, and its adverse neural consequences, is also a fertile new area of research, reflecting how the brain of individuals with psychiatric illness may be vulnerable to peripheral inflammation and diseases.

Thus, psychiatric research should focus on exploring and detecting molecular signatures (ie, biomarkers) of psychiatric disorders, including biomarkers of axonal and synaptic damage, glial activation, and oxidative stress. This is especially critical given the extensive heterogeneity of schizophrenia and mood and anxiety disorders. The CSF is a vastly unexploited substrate for discovering molecular biomarkers that will pave the way to precision psychiatry, and possibly open the door for completely new therapeutic strategies to tackle the most challenging neuropsychiatric disorders.

A role for CSF analysis

It’s quite puzzling why acute psychiatric episodes of schizophrenia, bipolar disorder, major depressive disorder, or panic attacks are not routinely assessed with a spinal tap, in conjunction with other brain measures such as neuroimaging (morphology, spectroscopy, cerebral blood flow, and diffusion tensor imaging) as well as a comprehensive neurocognitive examination and neurophysiological tests such as pre-pulse inhibition, mismatch negativity, and P-50, N-10, and P-300 evoked potentials. Combining CSF analysis with all those measures may help us stratify the spectra of psychosis, depression, and anxiety, as well as posttraumatic stress disorder and obsessive-compulsive disorder, into unique biotypes with overlapping clinical phenotypes and specific treatment approaches.

There are relatively few published CSF studies in psychiatric patients (mostly schizophrenia and bipolar and depressive disorders). The Table^1-9 shows some of those findings. More than 365 biomarkers have been reported in schizophrenia, most of them in serum and tissue.¹⁰ However, none of them can be used for diagnostic purposes because schizophrenia is a syndrome comprised of several hundred different diseases (biotypes) that have similar clinical symptoms. Many of the serum and tissue biomarkers have not been studied in CSF, and they must if advances in the neurobiology and treatment of the psychotic and mood spectra are to be achieved. And adapting the CSF biomarkers described in neurologic disorders such as multiple sclerosis¹¹ to schizophrenia and bipolar disorder (which also have well-established myelin pathologies) may yield a trove of neurobiologic findings.

If CSF studies eventually prove to be very useful for identifying subtypes for diagnosis and treatment, psychiatrists do not have to do the lumbar puncture themselves, but may refer patients to a “spinal tap” laboratory, just as they refer patients to a phlebotomy laboratory for routine blood tests. The adoption of CSF assessment in psychiatry will solidify its status as a clinical neuroscience, like its sister, neurology.

Psychiatry and neurology are the brain’s twin medical disciplines. Unlike neurologic brain disorders, where localizing the “lesion” is a primary objective, psychiatric brain disorders are much more subtle, with no “gross” lesions but numerous cellular and molecular pathologies within neural circuits.

Measuring the molecular components of the cerebrospinal fluid (CSF), the glorious “sewage system” of the brain, may help reveal granular clues to the neurobiology of psychiatric disorders.

Mental illnesses involve the disruption of brain structures and functions in a diffuse manner across the cortex. Abnormal neuroplasticity has been implicated in several major psychiatric disorders. Examples include hypoplasia of the hippocampus in major depressive disorder and cortical thinning/dysplasia in schizophrenia. Reductions of neurotropic factors such as nerve growth factor or brain-derived neurotropic factor have been reported in mood and psychotic disorders, and appear to correlate with neuroplasticity changes.

Recent advances in psychiatric neuroscience have provided many clues to the pathophysiology of psychopathological conditions, including neuroinflammation, oxidative stress, apoptosis, impaired energy metabolism, abnormal metabolomics and lipidomics, and hypo- and hyperfunction of various neurotransmitters systems (especially glutamate N-methyl-D-aspartate receptors, dopamine D2 receptors, serotonin 5-HT2A receptors, and gamma-amino­butyric acid receptors). Gray matter neurodegenerative changes as well as myelin disintegration in various psychiatric disorders point to significant neuropil and white matter pathologies across major psychiatric disorders. Dysfunctional glial cells (astroglia, microglia, and oligodendroglia) have also emerged as a central abnormality in psychiatric disorders. Permeability of the blood-brain barrier, and its adverse neural consequences, is also a fertile new area of research, reflecting how the brain of individuals with psychiatric illness may be vulnerable to peripheral inflammation and diseases.

Thus, psychiatric research should focus on exploring and detecting molecular signatures (ie, biomarkers) of psychiatric disorders, including biomarkers of axonal and synaptic damage, glial activation, and oxidative stress. This is especially critical given the extensive heterogeneity of schizophrenia and mood and anxiety disorders. The CSF is a vastly unexploited substrate for discovering molecular biomarkers that will pave the way to precision psychiatry, and possibly open the door for completely new therapeutic strategies to tackle the most challenging neuropsychiatric disorders.

A role for CSF analysis

It’s quite puzzling why acute psychiatric episodes of schizophrenia, bipolar disorder, major depressive disorder, or panic attacks are not routinely assessed with a spinal tap, in conjunction with other brain measures such as neuroimaging (morphology, spectroscopy, cerebral blood flow, and diffusion tensor imaging) as well as a comprehensive neurocognitive examination and neurophysiological tests such as pre-pulse inhibition, mismatch negativity, and P-50, N-10, and P-300 evoked potentials. Combining CSF analysis with all those measures may help us stratify the spectra of psychosis, depression, and anxiety, as well as posttraumatic stress disorder and obsessive-compulsive disorder, into unique biotypes with overlapping clinical phenotypes and specific treatment approaches.

There are relatively few published CSF studies in psychiatric patients (mostly schizophrenia and bipolar and depressive disorders). The Table^1-9 shows some of those findings. More than 365 biomarkers have been reported in schizophrenia, most of them in serum and tissue.¹⁰ However, none of them can be used for diagnostic purposes because schizophrenia is a syndrome comprised of several hundred different diseases (biotypes) that have similar clinical symptoms. Many of the serum and tissue biomarkers have not been studied in CSF, and they must if advances in the neurobiology and treatment of the psychotic and mood spectra are to be achieved. And adapting the CSF biomarkers described in neurologic disorders such as multiple sclerosis¹¹ to schizophrenia and bipolar disorder (which also have well-established myelin pathologies) may yield a trove of neurobiologic findings.

If CSF studies eventually prove to be very useful for identifying subtypes for diagnosis and treatment, psychiatrists do not have to do the lumbar puncture themselves, but may refer patients to a “spinal tap” laboratory, just as they refer patients to a phlebotomy laboratory for routine blood tests. The adoption of CSF assessment in psychiatry will solidify its status as a clinical neuroscience, like its sister, neurology.

Psychiatry and neurology are the brain’s twin medical disciplines. Unlike neurologic brain disorders, where localizing the “lesion” is a primary objective, psychiatric brain disorders are much more subtle, with no “gross” lesions but numerous cellular and molecular pathologies within neural circuits.

Measuring the molecular components of the cerebrospinal fluid (CSF), the glorious “sewage system” of the brain, may help reveal granular clues to the neurobiology of psychiatric disorders.

Mental illnesses involve the disruption of brain structures and functions in a diffuse manner across the cortex. Abnormal neuroplasticity has been implicated in several major psychiatric disorders. Examples include hypoplasia of the hippocampus in major depressive disorder and cortical thinning/dysplasia in schizophrenia. Reductions of neurotropic factors such as nerve growth factor or brain-derived neurotropic factor have been reported in mood and psychotic disorders, and appear to correlate with neuroplasticity changes.

Recent advances in psychiatric neuroscience have provided many clues to the pathophysiology of psychopathological conditions, including neuroinflammation, oxidative stress, apoptosis, impaired energy metabolism, abnormal metabolomics and lipidomics, and hypo- and hyperfunction of various neurotransmitters systems (especially glutamate N-methyl-D-aspartate receptors, dopamine D2 receptors, serotonin 5-HT2A receptors, and gamma-amino­butyric acid receptors). Gray matter neurodegenerative changes as well as myelin disintegration in various psychiatric disorders point to significant neuropil and white matter pathologies across major psychiatric disorders. Dysfunctional glial cells (astroglia, microglia, and oligodendroglia) have also emerged as a central abnormality in psychiatric disorders. Permeability of the blood-brain barrier, and its adverse neural consequences, is also a fertile new area of research, reflecting how the brain of individuals with psychiatric illness may be vulnerable to peripheral inflammation and diseases.

Thus, psychiatric research should focus on exploring and detecting molecular signatures (ie, biomarkers) of psychiatric disorders, including biomarkers of axonal and synaptic damage, glial activation, and oxidative stress. This is especially critical given the extensive heterogeneity of schizophrenia and mood and anxiety disorders. The CSF is a vastly unexploited substrate for discovering molecular biomarkers that will pave the way to precision psychiatry, and possibly open the door for completely new therapeutic strategies to tackle the most challenging neuropsychiatric disorders.

A role for CSF analysis

It’s quite puzzling why acute psychiatric episodes of schizophrenia, bipolar disorder, major depressive disorder, or panic attacks are not routinely assessed with a spinal tap, in conjunction with other brain measures such as neuroimaging (morphology, spectroscopy, cerebral blood flow, and diffusion tensor imaging) as well as a comprehensive neurocognitive examination and neurophysiological tests such as pre-pulse inhibition, mismatch negativity, and P-50, N-10, and P-300 evoked potentials. Combining CSF analysis with all those measures may help us stratify the spectra of psychosis, depression, and anxiety, as well as posttraumatic stress disorder and obsessive-compulsive disorder, into unique biotypes with overlapping clinical phenotypes and specific treatment approaches.

There are relatively few published CSF studies in psychiatric patients (mostly schizophrenia and bipolar and depressive disorders). The Table^1-9 shows some of those findings. More than 365 biomarkers have been reported in schizophrenia, most of them in serum and tissue.¹⁰ However, none of them can be used for diagnostic purposes because schizophrenia is a syndrome comprised of several hundred different diseases (biotypes) that have similar clinical symptoms. Many of the serum and tissue biomarkers have not been studied in CSF, and they must if advances in the neurobiology and treatment of the psychotic and mood spectra are to be achieved. And adapting the CSF biomarkers described in neurologic disorders such as multiple sclerosis¹¹ to schizophrenia and bipolar disorder (which also have well-established myelin pathologies) may yield a trove of neurobiologic findings.

If CSF studies eventually prove to be very useful for identifying subtypes for diagnosis and treatment, psychiatrists do not have to do the lumbar puncture themselves, but may refer patients to a “spinal tap” laboratory, just as they refer patients to a phlebotomy laboratory for routine blood tests. The adoption of CSF assessment in psychiatry will solidify its status as a clinical neuroscience, like its sister, neurology.

While today “The Big Lie” mainly refers to the actions of the prior President, an older and bigger lie that has a real effect on every American is one perpetrated by our very own health care conglomerate. Americans pay the highest rates for health care on the planet; health care consumes about 17% of our gross domestic product.¹ If we got higher-quality care, faster services, longer lives, or even greater consumer happiness, paying those rates might be worth it. But we don’t.

Worse yet is the idea that “board certification” assures the public that the doctor from whom they receive/purchase care is of a higher quality than one who is not so credentialed. That is our “Big Lie!” For decades, the public has been told that they should seek out board-certified doctors. Doctors in training have been told they must get board-certified. Hospitals brag about employing only board-certified doctors, insurers sometimes mandate board certification for a doctor to get paid, and employers use board certification as a benchmark for hiring and as a factor in compensation.

The sacred secret is that board certification makes no difference. There is no substantial evidence in any branch of medicine that doctors who are board-certified are better. There is no evidence that board-certified doctors get their patients healthier with more frequency, faster, less expensively, or with fewer medical errors than other doctors. The reality is that board certification is a sham. It’s a certificate granted after taking a very expensive test, and it is now part of an industry that is misleading the public and harming the trust the medical profession had once earned. Board certification is the equivalent of a diploma mill or an online certificate in any other field.

Why has this been kept under wraps for so long? Follow the money. The American Board of Medical Specialties (ABMS) oversees 24 specialty boards and reported revenue of $22.2M and expenses of $19.3M on its 2019 IRS Form 990.² They make profit every year. But, looking further, these “not-for-profit” educational entities are sitting on hundreds of millions of dollars in their “foundations.” Take the American Board of Psychiatry and Neurology, for instance. They had more than $140M in assets in 2019.³ How is this possible? Easy. They have misled the American public and been remarkably successful convincing other organizations, such as the Joint Commission, the Accreditation Council for Graduate Medical Education, and the National Committee for Quality Assurance, that board certification is an assurance of quality. They charge high fees to “candidates” for taking the computer-based test and have developed a system called maintenance of certification (MOC) that is onerous, expensive, and serves as an annuity that forces doctors to pay annually to keep their board certification.

Medicine is a science. In the practice of our discipline, we are expected to follow the science and to adhere to scientific principles. Yet there is neither scientific proof nor good evidence that board certification means anything in terms of competence, safety to the public, or quality of care. Doctors favor life-long learning, and continuing education has long been the standard and should remain so, not board certification or MOC. The mandatory continuing education required in every state to maintain a medical license is sufficient to prove doctors are current in their field of practice and to protect the public.

It is time for the medical community to admit that the emperor wears no clothes, and demand that the money grab of the ABMS and its affiliates be halted. This would result in greater access to care for patients and would reduce the cost of medical care, as the hundreds of millions being “stolen” from doctors today—costs that get passed on to patients—could be recouped and used for treating patients who clearly are in need and are being forgotten as the medical-industrial complex continues to flex its muscles and ensnare more of our national budget in its tentacles.

Neil S. Kaye, MD, DLFAPA
Hockessin, Delaware

While today “The Big Lie” mainly refers to the actions of the prior President, an older and bigger lie that has a real effect on every American is one perpetrated by our very own health care conglomerate. Americans pay the highest rates for health care on the planet; health care consumes about 17% of our gross domestic product.¹ If we got higher-quality care, faster services, longer lives, or even greater consumer happiness, paying those rates might be worth it. But we don’t.

Worse yet is the idea that “board certification” assures the public that the doctor from whom they receive/purchase care is of a higher quality than one who is not so credentialed. That is our “Big Lie!” For decades, the public has been told that they should seek out board-certified doctors. Doctors in training have been told they must get board-certified. Hospitals brag about employing only board-certified doctors, insurers sometimes mandate board certification for a doctor to get paid, and employers use board certification as a benchmark for hiring and as a factor in compensation.

The sacred secret is that board certification makes no difference. There is no substantial evidence in any branch of medicine that doctors who are board-certified are better. There is no evidence that board-certified doctors get their patients healthier with more frequency, faster, less expensively, or with fewer medical errors than other doctors. The reality is that board certification is a sham. It’s a certificate granted after taking a very expensive test, and it is now part of an industry that is misleading the public and harming the trust the medical profession had once earned. Board certification is the equivalent of a diploma mill or an online certificate in any other field.

Why has this been kept under wraps for so long? Follow the money. The American Board of Medical Specialties (ABMS) oversees 24 specialty boards and reported revenue of $22.2M and expenses of $19.3M on its 2019 IRS Form 990.² They make profit every year. But, looking further, these “not-for-profit” educational entities are sitting on hundreds of millions of dollars in their “foundations.” Take the American Board of Psychiatry and Neurology, for instance. They had more than $140M in assets in 2019.³ How is this possible? Easy. They have misled the American public and been remarkably successful convincing other organizations, such as the Joint Commission, the Accreditation Council for Graduate Medical Education, and the National Committee for Quality Assurance, that board certification is an assurance of quality. They charge high fees to “candidates” for taking the computer-based test and have developed a system called maintenance of certification (MOC) that is onerous, expensive, and serves as an annuity that forces doctors to pay annually to keep their board certification.

Medicine is a science. In the practice of our discipline, we are expected to follow the science and to adhere to scientific principles. Yet there is neither scientific proof nor good evidence that board certification means anything in terms of competence, safety to the public, or quality of care. Doctors favor life-long learning, and continuing education has long been the standard and should remain so, not board certification or MOC. The mandatory continuing education required in every state to maintain a medical license is sufficient to prove doctors are current in their field of practice and to protect the public.

It is time for the medical community to admit that the emperor wears no clothes, and demand that the money grab of the ABMS and its affiliates be halted. This would result in greater access to care for patients and would reduce the cost of medical care, as the hundreds of millions being “stolen” from doctors today—costs that get passed on to patients—could be recouped and used for treating patients who clearly are in need and are being forgotten as the medical-industrial complex continues to flex its muscles and ensnare more of our national budget in its tentacles.

Neil S. Kaye, MD, DLFAPA
Hockessin, Delaware

While today “The Big Lie” mainly refers to the actions of the prior President, an older and bigger lie that has a real effect on every American is one perpetrated by our very own health care conglomerate. Americans pay the highest rates for health care on the planet; health care consumes about 17% of our gross domestic product.¹ If we got higher-quality care, faster services, longer lives, or even greater consumer happiness, paying those rates might be worth it. But we don’t.

Worse yet is the idea that “board certification” assures the public that the doctor from whom they receive/purchase care is of a higher quality than one who is not so credentialed. That is our “Big Lie!” For decades, the public has been told that they should seek out board-certified doctors. Doctors in training have been told they must get board-certified. Hospitals brag about employing only board-certified doctors, insurers sometimes mandate board certification for a doctor to get paid, and employers use board certification as a benchmark for hiring and as a factor in compensation.

The sacred secret is that board certification makes no difference. There is no substantial evidence in any branch of medicine that doctors who are board-certified are better. There is no evidence that board-certified doctors get their patients healthier with more frequency, faster, less expensively, or with fewer medical errors than other doctors. The reality is that board certification is a sham. It’s a certificate granted after taking a very expensive test, and it is now part of an industry that is misleading the public and harming the trust the medical profession had once earned. Board certification is the equivalent of a diploma mill or an online certificate in any other field.

Why has this been kept under wraps for so long? Follow the money. The American Board of Medical Specialties (ABMS) oversees 24 specialty boards and reported revenue of $22.2M and expenses of $19.3M on its 2019 IRS Form 990.² They make profit every year. But, looking further, these “not-for-profit” educational entities are sitting on hundreds of millions of dollars in their “foundations.” Take the American Board of Psychiatry and Neurology, for instance. They had more than $140M in assets in 2019.³ How is this possible? Easy. They have misled the American public and been remarkably successful convincing other organizations, such as the Joint Commission, the Accreditation Council for Graduate Medical Education, and the National Committee for Quality Assurance, that board certification is an assurance of quality. They charge high fees to “candidates” for taking the computer-based test and have developed a system called maintenance of certification (MOC) that is onerous, expensive, and serves as an annuity that forces doctors to pay annually to keep their board certification.

Medicine is a science. In the practice of our discipline, we are expected to follow the science and to adhere to scientific principles. Yet there is neither scientific proof nor good evidence that board certification means anything in terms of competence, safety to the public, or quality of care. Doctors favor life-long learning, and continuing education has long been the standard and should remain so, not board certification or MOC. The mandatory continuing education required in every state to maintain a medical license is sufficient to prove doctors are current in their field of practice and to protect the public.

It is time for the medical community to admit that the emperor wears no clothes, and demand that the money grab of the ABMS and its affiliates be halted. This would result in greater access to care for patients and would reduce the cost of medical care, as the hundreds of millions being “stolen” from doctors today—costs that get passed on to patients—could be recouped and used for treating patients who clearly are in need and are being forgotten as the medical-industrial complex continues to flex its muscles and ensnare more of our national budget in its tentacles.

Neil S. Kaye, MD, DLFAPA
Hockessin, Delaware