As Covid-19 cases reach a record high in the U.S., models project that this third wave of the pandemic may be the worst yet. The confluence of weather patterns, pandemic fatigue, loose social distancing guidelines, and the upcoming flu season have led to a surge of hospitalizations that will continue to rise over the next few months.
Concerns are once again growing about hospital capacity in terms of available beds and equipment, as well as the availability of frontline health care providers and how to keep them from getting Covid-19. One looming shortage that has been overlooked is the shortage of providers with experience in treating hospitalized patients.
Most physicians in the U.S. stop treating patients in the hospital when they complete their residencies or fellowships. This lack of experience could have a significant impact on patient outcomes and should be considered in pandemic planning.
In the past, physicians treated patients across different settings, often attending to their patients when they were hospitalized or admitted to a nursing home. Since the 1990s, some generalist physicians have focused their practice exclusively on hospitalized patients. They have come to be known as hospitalists. This trend of some physicians seeing patients solely in the hospital and others seeing patients primarily in clinic settings has major implications during a pandemic in which 20% of people infected with SARS-CoV-2 need to be hospitalized.
In a study recently published in the Journal of General Internal Medicine, we found that fewer than half of U.S. physicians across specialties treated hospitalized patients. The number of physicians with experience treating hospitalized patients fell even lower when we applied additional exclusions, such as age over 65, which is a risk factor for severe Covid-19.
The availability of physicians experienced in hospital practice also differed by region. We estimated that 35 states will face shortages of physicians with recent experience treating hospitalized patients at the projected peak of the pandemic.
Hospital experience is important because physicians with it may provide higher-quality care than those without it. Differences in care quality could stem from four main factors. First, experienced physicians have better knowledge and expertise of the clinical presentations and complications commonly seen among hospitalized patients. Second, experience brings practical knowledge of the hospital, such as professional relationships with other staff — nurses, social workers, physical therapists, and the like — or care processes that may be unique to the institution. Third, prior experience with hospital medicine can lead to more efficient patient care, including shorter and cheaper hospital stays, and better familiarity with discharge practices. Fourth, physicians who work in hospitals organize their internal practice processes, such as scheduling and cross coverage for off-duty physicians, in ways that are better aligned with the needs of hospitalized patients.
We believe that health care systems should consider physician experience in treating hospitalized patients as an important constraint when assessing their capacity for the upcoming surge of Covid-19. Those that anticipate a shortage of such providers should implement training protocols to prepare non-hospitalist physicians to work in the hospital when Covid-19 cases surge. Our findings, combined with reports from the Centers for Disease Control and Prevention that health care workers hospitalized with Covid-19 are often younger than other hospitalized patients, provide a rationale for more thoughtful deployment of health care workers during the pandemic.
There is also evidence that different hospitals in the same state, and even the same city, can have vastly different death rates due to differences in resources. If states were to publicly report Covid-19 hospitalization rates and mortality and reallocate resources — including physicians with experience treating patients in the hospital — or transfer patients to hospitals that are better able to meet the needs of Covid-19 patients, they would likely receive better care. The national system of inter-hospital transfers created by the CDC needs to be more robust to ensure that patients do not suffer due to shortages of experienced physicians.
Telemedicine and remote diagnostics can obviate the need to physically transfer patients or physicians, making investments in the technology and the elimination of regulatory barriers that preclude efficient telemedicine consultation urgently needed.
Health systems and states should consider the availability of physicians with experience treating hospitalized patients in their pandemic planning. Anticipating and addressing shortages of these physicians could save lives in this pandemic and help plan for the next one.
Anjali Bhatla is an M.D./MBA candidate at the Perelman School of Medicine at the University of Pennsylvania and the Wharton School. Kira L. Ryskina is an internal medicine physician, a senior fellow at the Leonard Davis Institute of Health Economics, and an assistant professor of medicine in the Division of General Internal Medicine at the University of Pennsylvania.
Just a thought that perhaps telehealth provided by retired/or overtime /hospitalists/internists/Critical care providers could augment the bedside care by the hospitalist in these extreme circumstances–e.g. a pool of willing providers that could give input to the nurses at the bedside if their hospital physician is tied up elsewhere